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Submitted URL: https://advancecare.pt/formularios/pedidos-dac
Effective URL: https://www.advancecare.pt/para-si/ajuda/fale-connosco
Submission: On May 27 via api from PT — Scanned from PT
Effective URL: https://www.advancecare.pt/para-si/ajuda/fale-connosco
Submission: On May 27 via api from PT — Scanned from PT
Form analysis 5 forms found in the DOM
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<div data-sc-field-key="4F1E19CBF6A44BF0B00E4E8AE6CED4B0" class="row">
<div data-sc-field-key="2820FD0F32734C54AE045C32BE24BE39" class="col-lg-12 col-sm-12">
<span data-sc-field-key="8E076CC641464F50B1FAC4999070E652" class="form-field--text pt-5"> Na utilização deste formulário o utilizador deve tomar conhecimento das seguintes disposições uma vez que é solicitado que forneça previamente dados
pessoais. A AdvanceCare S.A é a responsável pelo tratamento dos dados recolhidos neste formulário. Os contactos do responsável e do encarregado da proteção de dados estão disponíveis
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/formularios/gestao-de-dados-pessoais">aqui</a>.</span>
<span data-sc-field-key="7576656B93D0404083217BC1958363FF" class="form-field--text "> Caso o utilizador efetue o seu pedido no âmbito do seu seguro ou plano de benefícios de saúde, a AdvanceCare atua como subcontratante e o fundamento jurídico
para o tratamento é a execução enquanto subcontratante das diligências para resposta ao contrato com a seguradora/entidade na gestão de seguros/planos de saúde. Para mais detalhe consulte
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/protecao-de-dados-pessoais">aqui</a>.</span>
<span data-sc-field-key="D27063C58E364D379606B31EB6D02E68" class="form-field--text "> O titular dos dados poderá, em qualquer momento, exercer os direitos, veja mais detalhe
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/formularios/gestao-de-dados-pessoais">aqui</a></span>
<h6 data-sc-field-key="1F2AD1DB94B2469AA72D81C8FB2A4BF2" class="pt-3">Por favor, preencha os seguintes dados:</h6><input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_565f1587-b145-4438-a3f0-5f17afbe480a"
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name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[565f1587-b145-4438-a3f0-5f17afbe480a].ItemId" type="hidden" value="565f1587-b145-4438-a3f0-5f17afbe480a"><label
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<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[565f1587-b145-4438-a3f0-5f17afbe480a].Value" data-valmsg-replace="true"></span>
<div class="form-custom-select">
<div class="select-selected"></div>
<div class="select-items select-hide">
<div></div>
<div>Reclamação</div>
</div>
</div>
<select id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_565f1587-b145-4438-a3f0-5f17afbe480a__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[565f1587-b145-4438-a3f0-5f17afbe480a].Value" class="form-control"
data-sc-tracking="True" data-sc-field-name="seguro-ou-plano-de-saude" data-sc-field-key="169E97D2837840559168A3F98A7A57CA">
<option label=" "></option>
<option value="reclamacoes@advancecare.com">Reclamação</option>
</select>
<label data-sc-field-key="4E4BE773CA6D424A9FD7D2DACB04B09D" class="" style="display: none;">Para outros assuntos não relacionados com o tema selecionado, utilize a nossa plataforma myAdvanceCare ou contacte-nos pelos canais alternativos
disponíveis no verso do seu cartão. Pedidos de reembolso por esta via não são aceites.</label>
<span data-sc-field-key="D52C007100904A98BCB0252C0D146D5A" class="form-field--text pt-4" style="display: none;"> Com o objetivo de melhorar a qualidade dos serviços prestados e com o intuito de promover a melhoria contínua dos nossos serviços,
a AdvanceCare, entidade certificada pelo referencial da Qualidade NP EN ISO 9001, disponibiliza através deste portal um formulário de reclamações. Conheça a nossa política de reclamações
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/gestao-reclamacoes">aqui</a>.</span>
<div data-sc-field-key="AFAECDD202134793BAC90833CB3EAE5D" class="">
<h4 data-sc-field-key="CDBDD574660B42399CEBF3301BA7E1DA" class="pt-4 bold" style="display: none;">Dados do lesado</h4><input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_18c032fd-78b9-4066-a47e-a363c615144f"
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for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_18c032fd-78b9-4066-a47e-a363c615144f__Value" class="pt-4 bold">Subsistema ou Seguradora *</label>
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[18c032fd-78b9-4066-a47e-a363c615144f].Value" data-valmsg-replace="true"></span>
<div class="form-custom-select">
<div class="select-selected"></div>
<div class="select-items select-hide">
<div></div>
<div>Açoreana</div>
<div>Asisa</div>
<div>BNP Paribas Cardif</div>
<div>Cimentaçor</div>
<div>Cimpor Industria</div>
<div>Cruz Vermelha Portuguesa</div>
<div>Europ Assistance</div>
<div>Generali </div>
<div>Mudum Seguros</div>
<div>Intercement</div>
<div>LOGO</div>
<div>Lusitania</div>
<div>MGEN - Mutuelle Générale de L Education National</div>
<div>N Seguros</div>
<div>Popular Seguros</div>
<div>Real Vida Seguros</div>
<div>SAMS SBC </div>
<div>SAMS Mais Sindicato</div>
<div>Santander Totta Seguros</div>
<div>Tranquilidade</div>
<div>UNA Seguros</div>
<div>União das Misericórdias Portuguesas</div>
<div>Vitorino Seguros</div>
</div>
</div>
<select id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_18c032fd-78b9-4066-a47e-a363c615144f__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[18c032fd-78b9-4066-a47e-a363c615144f].Value" class="form-control"
data-sc-tracking="True" data-sc-field-name="SeguradoraSubsistema" data-sc-field-key="8C26E1861FD94502A1FF7B0BF358C47A" data-val-required=" " data-val="true">
<option label=" "></option>
<option value="Açoreana">Açoreana</option>
<option value="Asisa">Asisa</option>
<option value="BNP Paribas Cardif">BNP Paribas Cardif</option>
<option value="Cimentaçor">Cimentaçor</option>
<option value="Cimpor Industria">Cimpor Industria</option>
<option value="Cruz Vermelha Portuguesa">Cruz Vermelha Portuguesa</option>
<option value="Europ Assistance">Europ Assistance</option>
<option value="Generali ">Generali </option>
<option value="Mudum Seguros">Mudum Seguros</option>
<option value="Intercement">Intercement</option>
<option value="LOGO">LOGO</option>
<option value="Lusitania">Lusitania</option>
<option value="MGEN - Mutuelle Générale de L Education National">MGEN - Mutuelle Générale de L Education National</option>
<option value="N Seguros">N Seguros</option>
<option value="Popular Seguros">Popular Seguros</option>
<option value="Real Vida Seguros">Real Vida Seguros</option>
<option value="SAMS SBC">SAMS SBC </option>
<option value="SAMS Mais Sindicato">SAMS Mais Sindicato</option>
<option value="Santander Totta Seguros">Santander Totta Seguros</option>
<option value="Tranquilidade">Tranquilidade</option>
<option value="UNA Seguros">UNA Seguros</option>
<option value="União das Misericórdias Portuguesas">União das Misericórdias Portuguesas</option>
<option value="Vitorino Seguros">Vitorino Seguros</option>
</select>
</div>
<div data-sc-field-key="9BDD4945B540401AA1E112D489102E77" class="">
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_52ea9dec-042b-4565-a3f1-cca2bc4b53cc" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="52ea9dec-042b-4565-a3f1-cca2bc4b53cc"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_52ea9dec-042b-4565-a3f1-cca2bc4b53cc__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[52ea9dec-042b-4565-a3f1-cca2bc4b53cc].ItemId" type="hidden"
value="52ea9dec-042b-4565-a3f1-cca2bc4b53cc"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_52ea9dec-042b-4565-a3f1-cca2bc4b53cc__Value" class="pt-4 bold">Nº do cartão do seguro de saúde / plano de benefícios:</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_52ea9dec-042b-4565-a3f1-cca2bc4b53cc__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[52ea9dec-042b-4565-a3f1-cca2bc4b53cc].Value" class="form-control" type="text"
value="" maxlength="255" placeholder=" Número que consta na frente do cartão do seu seguro de saúde/plano de benefícios" data-sc-tracking="True" data-sc-field-name="Ncartao" data-sc-field-key="F46F7923682B4695BC0EB209BAF1CC24">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[52ea9dec-042b-4565-a3f1-cca2bc4b53cc].Value" data-valmsg-replace="true"></span>
<p data-sc-field-key="3C89EDAA322E42F888D136B2EFDD05B1" class="">Número que consta na frente do cartão do seu seguro de saúde / plano de benefícios</p><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_1d53ce10-1222-47de-a989-f6b273d7a069" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="1d53ce10-1222-47de-a989-f6b273d7a069"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_1d53ce10-1222-47de-a989-f6b273d7a069__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[1d53ce10-1222-47de-a989-f6b273d7a069].ItemId" type="hidden"
value="1d53ce10-1222-47de-a989-f6b273d7a069"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_1d53ce10-1222-47de-a989-f6b273d7a069__Value" class="pt-4 bold">NIF *</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_1d53ce10-1222-47de-a989-f6b273d7a069__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[1d53ce10-1222-47de-a989-f6b273d7a069].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="NIF" data-sc-tracking="True" data-sc-field-name="niflesado" data-sc-field-key="6CE9113399DA41C788BC1E45051753DD" data-val-validnif="" data-val-validnif-nif="" data-val-required=" " data-val="true">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[1d53ce10-1222-47de-a989-f6b273d7a069].Value" data-valmsg-replace="true"></span><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_850f55c3-7483-4a4c-afb6-f75676335d71" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="850f55c3-7483-4a4c-afb6-f75676335d71"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_850f55c3-7483-4a4c-afb6-f75676335d71__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[850f55c3-7483-4a4c-afb6-f75676335d71].ItemId" type="hidden"
value="850f55c3-7483-4a4c-afb6-f75676335d71"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_850f55c3-7483-4a4c-afb6-f75676335d71__Value" class="pt-4 bold">Email *</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_850f55c3-7483-4a4c-afb6-f75676335d71__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[850f55c3-7483-4a4c-afb6-f75676335d71].Value" class="form-control" type="email"
value="" maxlength="255" placeholder="exemplo@exemplo.pt" data-sc-tracking="True" data-sc-field-name="Email" data-sc-field-key="70A3587653514150974BF7C6FDF60943" data-val-regex="Por favor, introduza um endereço eletrónico válido."
data-val-regex-pattern="^[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,17}$" data-val-required=" " data-val="true">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[850f55c3-7483-4a4c-afb6-f75676335d71].Value" data-valmsg-replace="true"></span><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_f80a9954-395f-40d8-86dc-c9071bc361c8" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="f80a9954-395f-40d8-86dc-c9071bc361c8"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_f80a9954-395f-40d8-86dc-c9071bc361c8__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[f80a9954-395f-40d8-86dc-c9071bc361c8].ItemId" type="hidden"
value="f80a9954-395f-40d8-86dc-c9071bc361c8"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_f80a9954-395f-40d8-86dc-c9071bc361c8__Value" class="pt-4 bold" style="display: none;">Nº de bilhete de identidade / Cartão de cidadão
*</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_f80a9954-395f-40d8-86dc-c9071bc361c8__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[f80a9954-395f-40d8-86dc-c9071bc361c8].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Nº de bilhete de identidade / Cartão de cidadão" data-sc-tracking="True" data-sc-field-name="Single-Line Text" data-sc-field-key="2D55E88DCB354432957A304B51B86539" data-val-required=" " data-val="true"
disabled="" style="display: none;"><input type="hidden" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[f80a9954-395f-40d8-86dc-c9071bc361c8].Required" value="false" data-sc-conditions-required="">
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id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_5c1bfbd4-603d-48ec-a3ec-33a821e04e64__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[5c1bfbd4-603d-48ec-a3ec-33a821e04e64].ItemId" type="hidden"
value="5c1bfbd4-603d-48ec-a3ec-33a821e04e64"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_5c1bfbd4-603d-48ec-a3ec-33a821e04e64__Value" class="pt-4 bold" style="display: none;">Selecione o tipo de documento pretendido
*</label>
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[5c1bfbd4-603d-48ec-a3ec-33a821e04e64].Value" data-valmsg-replace="true"></span>
<div class="form-custom-select" style="display: none;">
<div class="select-selected"></div>
<div class="select-items select-hide">
<div></div>
<div>2ª via Termo de responsabilidade</div>
<div>Declaração de comparticipação</div>
</div>
</div>
<select id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_5c1bfbd4-603d-48ec-a3ec-33a821e04e64__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[5c1bfbd4-603d-48ec-a3ec-33a821e04e64].Value" class="form-control"
data-sc-tracking="True" data-sc-field-name="Tipo_documetos" data-sc-field-key="2AE84F45C0EA423F8F1B483E0DF2D854" data-val-required=" " data-val="true" disabled="" style="display: none;">
<option label=" "></option>
<option value="2ª via Termo de responsabilidade">2ª via Termo de responsabilidade</option>
<option value="Declaração de comparticipação">Declaração de comparticipação</option>
</select><input type="hidden" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[5c1bfbd4-603d-48ec-a3ec-33a821e04e64].Required" value="false" data-sc-conditions-required="">
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_57f83014-a4ee-4fda-b2f2-2766b41fcf55" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="57f83014-a4ee-4fda-b2f2-2766b41fcf55"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_57f83014-a4ee-4fda-b2f2-2766b41fcf55__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[57f83014-a4ee-4fda-b2f2-2766b41fcf55].ItemId" type="hidden"
value="57f83014-a4ee-4fda-b2f2-2766b41fcf55"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_57f83014-a4ee-4fda-b2f2-2766b41fcf55__Value" class="pt-4 bold" style="display: none;">Data da despesa/recibo *</label>
<input type="date" id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_57f83014-a4ee-4fda-b2f2-2766b41fcf55__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[57f83014-a4ee-4fda-b2f2-2766b41fcf55].Value" class="form-control"
data-sc-tracking="True" data-sc-field-name="DataEnvioDespesa" data-sc-field-key="F45B974363E249C9955D700A24A4749D" data-val-required=" " data-val-date="The field Value must be a date." data-val="true" disabled=""
style="display: none;"><input type="hidden" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[57f83014-a4ee-4fda-b2f2-2766b41fcf55].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[57f83014-a4ee-4fda-b2f2-2766b41fcf55].Value" data-valmsg-replace="true"></span><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_11c363df-3471-4d29-a400-468a5d847125" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="11c363df-3471-4d29-a400-468a5d847125"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_11c363df-3471-4d29-a400-468a5d847125__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[11c363df-3471-4d29-a400-468a5d847125].ItemId" type="hidden"
value="11c363df-3471-4d29-a400-468a5d847125"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_11c363df-3471-4d29-a400-468a5d847125__Value" class="pt-4 bold" style="display: none;">Valor da despesas *</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_11c363df-3471-4d29-a400-468a5d847125__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[11c363df-3471-4d29-a400-468a5d847125].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="0.00€" data-sc-tracking="True" data-sc-field-name="valdespesa" data-sc-field-key="1525187F4DD540B09F85DF75610DC340" data-val-required=" " data-val="true" disabled="" style="display: none;"><input
type="hidden" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[11c363df-3471-4d29-a400-468a5d847125].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[11c363df-3471-4d29-a400-468a5d847125].Value" data-valmsg-replace="true"></span>
</div>
<span data-sc-field-key="325705A6575241D9A289998814045F71" class="form-field--text pt-4" style="display: none;"> Para apresentar um pedido de esclarecimento, utilize por favor o seguinte link:
<a class="form-field-link" target="blank" href="https://www.mgen.pt/ajuda">www.mgen.pt/ajuda</a>. Em alternativa poderá enviar um email para saude@mgen.pt</span>
<span data-sc-field-key="8ECFF2C29E914188BD6A8788C2E027D9" class="form-field--text pt-4" style="display: none;"> Para apresentar uma reclamação, utilize por favor o seguinte link:
<a class="form-field-link" target="blank" href="https://www.mgen.pt/reclamacao">www.mgen.pt/reclamacao</a>. Em alternativa poderá enviar um email para reclamacoes@mgen.pt</span>
<div data-sc-field-key="C238451122904938B24AD9ECA4F80B1C" class="">
<h4 data-sc-field-key="88171157EC114CF29C2E16D6DBFF3D14" class="pt-4 bold" style="display: none;">Dados do reclamante</h4><input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_6f568f21-a43f-4bbd-a950-b32b14f681c7"
name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="6f568f21-a43f-4bbd-a950-b32b14f681c7"><input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_6f568f21-a43f-4bbd-a950-b32b14f681c7__ItemId"
name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[6f568f21-a43f-4bbd-a950-b32b14f681c7].ItemId" type="hidden" value="6f568f21-a43f-4bbd-a950-b32b14f681c7"><label
for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_6f568f21-a43f-4bbd-a950-b32b14f681c7__Value" class="pt-4 bold" style="display: none;">Relação com o lesado *</label>
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[6f568f21-a43f-4bbd-a950-b32b14f681c7].Value" data-valmsg-replace="true"></span>
<div class="form-custom-select" style="display: none;">
<div class="select-selected"></div>
<div class="select-items select-hide">
<div></div>
<div>Lesado</div>
<div>Corretor</div>
<div>Recursos humanos – Empresas</div>
<div>Advogado</div>
<div>Representante legal</div>
<div>Outro</div>
</div>
</div>
<select id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_6f568f21-a43f-4bbd-a950-b32b14f681c7__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[6f568f21-a43f-4bbd-a950-b32b14f681c7].Value" class="form-control"
data-sc-tracking="True" data-sc-field-name="relacaolesado" data-sc-field-key="31CE027CA57A49C4AA07869C832C8A0B" data-val-required=" " data-val="true" disabled="" style="display: none;">
<option label=" "></option>
<option value="Lesado">Lesado</option>
<option value="Corretor">Corretor</option>
<option value="Recursos humanos – Empresas">Recursos humanos – Empresas</option>
<option value="Advogado">Advogado</option>
<option value="Representante legal">Representante legal</option>
<option value="Outro">Outro</option>
</select><input type="hidden" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[6f568f21-a43f-4bbd-a950-b32b14f681c7].Required" value="false" data-sc-conditions-required="">
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_0a6ac3d7-941d-465f-b5c5-dadd9f496e20" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="0a6ac3d7-941d-465f-b5c5-dadd9f496e20"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_0a6ac3d7-941d-465f-b5c5-dadd9f496e20__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[0a6ac3d7-941d-465f-b5c5-dadd9f496e20].ItemId" type="hidden"
value="0a6ac3d7-941d-465f-b5c5-dadd9f496e20"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_0a6ac3d7-941d-465f-b5c5-dadd9f496e20__Value" class="pt-4 bold" style="display: none;">Nome do Corretor *</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_0a6ac3d7-941d-465f-b5c5-dadd9f496e20__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[0a6ac3d7-941d-465f-b5c5-dadd9f496e20].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Nome *" data-sc-tracking="True" data-sc-field-name="nomecorretor" data-sc-field-key="512C4F2568DC4DC0B01F0D5284792FCE" data-val-required=" " data-val="true" disabled="" style="display: none;"><input
type="hidden" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[0a6ac3d7-941d-465f-b5c5-dadd9f496e20].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[0a6ac3d7-941d-465f-b5c5-dadd9f496e20].Value" data-valmsg-replace="true"></span><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_0f91f99c-01b5-430e-9308-4a5299bf2ade" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="0f91f99c-01b5-430e-9308-4a5299bf2ade"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_0f91f99c-01b5-430e-9308-4a5299bf2ade__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[0f91f99c-01b5-430e-9308-4a5299bf2ade].ItemId" type="hidden"
value="0f91f99c-01b5-430e-9308-4a5299bf2ade"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_0f91f99c-01b5-430e-9308-4a5299bf2ade__Value" class="pt-4 bold" style="display: none;">Email do Corretor *</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_0f91f99c-01b5-430e-9308-4a5299bf2ade__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[0f91f99c-01b5-430e-9308-4a5299bf2ade].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="exemplo@exemplo.pt" data-sc-tracking="True" data-sc-field-name="emailcorretor" data-sc-field-key="59C26843D2BC4AC5A50B326DBC68A352" data-val-required=" " data-val="true" disabled=""
style="display: none;"><input type="hidden" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[0f91f99c-01b5-430e-9308-4a5299bf2ade].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[0f91f99c-01b5-430e-9308-4a5299bf2ade].Value" data-valmsg-replace="true"></span><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e].ItemId" type="hidden"
value="8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e__Value" class="pt-4 bold" style="display: none;">Telefone do Corretor *</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Telefone" data-sc-tracking="True" data-sc-field-name="telefonecorretor" data-sc-field-key="FA753FFB180048168A6CB611F0E3EFE3" data-val-required=" " data-val="true" disabled=""
style="display: none;"><input type="hidden" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[8d38d7f6-fb87-49b3-9f7b-eebfa4dae88e].Value" data-valmsg-replace="true"></span><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_6736ccf0-9722-48cb-8c3a-ba9643a5e9da" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="6736ccf0-9722-48cb-8c3a-ba9643a5e9da"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_6736ccf0-9722-48cb-8c3a-ba9643a5e9da__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[6736ccf0-9722-48cb-8c3a-ba9643a5e9da].ItemId" type="hidden"
value="6736ccf0-9722-48cb-8c3a-ba9643a5e9da"><label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_6736ccf0-9722-48cb-8c3a-ba9643a5e9da__Value" class="pt-4 bold">Mensagem *</label>
<textarea id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_6736ccf0-9722-48cb-8c3a-ba9643a5e9da__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[6736ccf0-9722-48cb-8c3a-ba9643a5e9da].Value" class="form-control" rows="6"
maxlength="1000" placeholder="Descreva de forma detalhada o motivo do seu contacto" data-sc-tracking="True" data-sc-field-name="mensagem" data-sc-field-key="136988472AB14E478210DE1BDAD61BBA" data-val-required=" " data-val="true"></textarea>
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[6736ccf0-9722-48cb-8c3a-ba9643a5e9da].Value" data-valmsg-replace="true"></span>
<h6 data-sc-field-key="B9689BCF54524D549BAB5784CFB1359E" class="bold pt-3 pb-3">Caso pretenda poderá adicionar aqui documentos úteis à sua exposição</h6><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_68140ed5-55df-4d1d-91de-2d853476eb42" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="68140ed5-55df-4d1d-91de-2d853476eb42"><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_68140ed5-55df-4d1d-91de-2d853476eb42__ItemId" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[68140ed5-55df-4d1d-91de-2d853476eb42].ItemId" type="hidden"
value="68140ed5-55df-4d1d-91de-2d853476eb42">
<div class="form-file-upload file-drag pt-4">
<span class="field-validation-valid" data-valmsg-for="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[68140ed5-55df-4d1d-91de-2d853476eb42].Files" data-valmsg-replace="true"></span>
<label for="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_68140ed5-55df-4d1d-91de-2d853476eb42__Files" class="adv-upload">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_68140ed5-55df-4d1d-91de-2d853476eb42__Files" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[68140ed5-55df-4d1d-91de-2d853476eb42].Files" class="file-drag pt-4" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="file" data-sc-field-key="EAEE287AE944429392BBB75A13866AEF" data-val-filesize="Tamanho do ficheiro incorrecto." data-val-filesize-max="10485760"
data-val-filetype="Por favor introduza um ficheiro com extensão válida." data-val-filetype-allowedcontenttypes=".pdf,.jpg,.tif,.png,.gif,.bmp,.doc,.docx,.msg,.xls,.xlsx,.txt" data-val="true"><button
class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="0736251B620249B08221FB440BFC06F3" class="small">Os ficheiros a carregar devem ter até 10MB, tendo em atenção o seu formato e qualidade ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de
dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens.</p>
<p data-sc-field-key="F155D6544E754B2592A18A862305A7EE" class="pt-4">(*) campos de preenchimento obrigatório, sob pena de não ser possível finalizar a submissão do pedido</p><input
id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_Index_1b72c8e8-2ec7-4b34-90d1-70a0e08e8ae3" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields.Index" type="hidden" value="1b72c8e8-2ec7-4b34-90d1-70a0e08e8ae3"><input
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value="1b72c8e8-2ec7-4b34-90d1-70a0e08e8ae3">
<div class="">
<input type="checkbox" id="fxb_7a7debda-4f2a-46b2-a8d4-c69e84b86946_Fields_1b72c8e8-2ec7-4b34-90d1-70a0e08e8ae3__Value" name="fxb.7a7debda-4f2a-46b2-a8d4-c69e84b86946.Fields[1b72c8e8-2ec7-4b34-90d1-70a0e08e8ae3].Value" class="checkbox"
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<span data-sc-field-key="6F981EE9FE274036902B523CC4ABE47E" class="form-field--text "> Declaro que li e aceito a
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<div data-sc-field-key="F49A5776CA6E4410BADF2CBD5494937F" class="row">
<div data-sc-field-key="FFF2D2987EBA48FF9C9985CBA38DDDB1" class="col-lg-12 col-sm-12">
<p data-sc-field-key="4D33E9913BB1454A88D7CFF4F765092E" class="">Se pretende apresentar uma reclamação no âmbito da aquisição de produtos do portal AdvanceCare, por favor preencha os campos abaixo apresentados.</p>
<span data-sc-field-key="16A5D0FAACF84FE8A62E8408E752A0F4" class="form-field--text pt-5"> Na utilização deste formulário o utilizador deve tomar conhecimento das seguintes disposições uma vez que é solicitado que forneça previamente dados
pessoais. A AdvanceCare S.A é a responsável pelo tratamento dos dados recolhidos neste formulário. Os contactos do responsável e do encarregado da proteção de dados estão disponíveis
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/formularios/gestao-de-dados-pessoais">aqui</a>.</span>
<span data-sc-field-key="F62F912559C5473E98E4B96304158E7D" class="form-field--text "> Os dados recolhidos destinam-se à análise do pedido e atualização de dados. O fundamento jurídico para o tratamento é a necessidade de realização de
diligências contratuais solicitadas. Para mais detalhe consulte <a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/protecao-de-dados-pessoais">aqui</a>.</span>
<span data-sc-field-key="8DF93E12E820433EAF747D1D07D7404B" class="form-field--text "> O titular dos dados poderá, em qualquer momento, exercer os direitos, veja mais detalhe
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/formularios/gestao-de-dados-pessoais">aqui</a>.</span>
<h6 data-sc-field-key="B76B9D89DAD6410099CB1C6A5994F880" class="pt-3">Por favor, preencha os seguintes dados:</h6><input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_724a0099-57da-4482-a79b-75fea9eb3a5d"
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for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_724a0099-57da-4482-a79b-75fea9eb3a5d__Value" class="pt-4 bold">Assunto *</label>
<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[724a0099-57da-4482-a79b-75fea9eb3a5d].Value" data-valmsg-replace="true"></span>
<div class="form-custom-select">
<div class="select-selected"></div>
<div class="select-items select-hide">
<div></div>
<div>Reclamações</div>
</div>
</div>
<select id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_724a0099-57da-4482-a79b-75fea9eb3a5d__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[724a0099-57da-4482-a79b-75fea9eb3a5d].Value" class=" form-control"
data-sc-tracking="True" data-sc-field-name="loja-online" data-sc-field-key="BF85DE30FF5340358760F4BC6290865D" data-val-required=" " data-val="true">
<option label=" "></option>
<option value="reclamacoes@advancecare.com">Reclamações</option>
</select>
<p data-sc-field-key="803957A87A3041E8B996E6A3A0B56CC4" class="" style="display: none;">Para outros assuntos não relacionados com o tema selecionado, utilize a nossa plataforma myAdvanceCare ou contacte-nos pelos canais alternativos disponíveis
no verso do seu cartão. Pedidos de reembolso por esta via não são aceites.</p>
<span data-sc-field-key="FF4B799CEE514389B168DB0667210A4A" class="form-field--text pt-5" style="display: none;"> Os cancelamentos podem ser feitos no prazo de 14 dias a contar da data de aquisição ou em situação previstas e devidamente
descritas em determinados produtos disponíveis em “loja online”. O envio do presente formulário não invalida o contacto prévio para o número 707 100 005 ou 210 192 816, onde deverá escolher a opção “cancelamento”. Para esclarecimento sobre
cancelamentos resultantes de livre resolução. Após correta anulação por parte da AdvanceCare, serão processados a nota de crédito e de reembolso da totalidade ou parte do valor do voucher, de acordo com a situação em causa.</span>
<span data-sc-field-key="07472C4AA6E44B6096C1EA2431D52E1D" class="form-field--text pt-5" style="display: none;"> Numa perspetiva de melhoria contínua da qualidade dos nossos serviços e da oferta disponibilizada, a AdvanceCare, entidade
certificada pelo referencial da Qualidade NP EN ISO 9001, disponibiliza através deste portal um formulário de reclamações. Se pretende apresentar uma reclamação no âmbito da aquisição de produtos do portal AdvanceCare, por favor preencha os
campos abaixo apresentados. Conheça a nossa política de reclamações à qual poderá aceder, clicando
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/gestao-reclamacoes">aqui</a>.</span><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_2eaf1eb3-a516-4e0a-9792-cec7751c8247" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="2eaf1eb3-a516-4e0a-9792-cec7751c8247"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_2eaf1eb3-a516-4e0a-9792-cec7751c8247__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[2eaf1eb3-a516-4e0a-9792-cec7751c8247].ItemId" type="hidden"
value="2eaf1eb3-a516-4e0a-9792-cec7751c8247"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_2eaf1eb3-a516-4e0a-9792-cec7751c8247__Value" class="pt-4 bold">Nome *</label>
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_2eaf1eb3-a516-4e0a-9792-cec7751c8247__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[2eaf1eb3-a516-4e0a-9792-cec7751c8247].Value" class=" form-control" type="text"
value="" maxlength="255" placeholder="Nome" data-sc-tracking="True" data-sc-field-name="nome" data-sc-field-key="9A0A0FA1C9CD4370BD95DCFDE3B2F872" data-val-required=" " data-val="true">
<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[2eaf1eb3-a516-4e0a-9792-cec7751c8247].Value" data-valmsg-replace="true"></span><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_1eb02d62-1429-4367-a003-c8c69c2d1b36" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="1eb02d62-1429-4367-a003-c8c69c2d1b36"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_1eb02d62-1429-4367-a003-c8c69c2d1b36__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[1eb02d62-1429-4367-a003-c8c69c2d1b36].ItemId" type="hidden"
value="1eb02d62-1429-4367-a003-c8c69c2d1b36"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_1eb02d62-1429-4367-a003-c8c69c2d1b36__Value" class="pt-4 bold">E-mail *</label>
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_1eb02d62-1429-4367-a003-c8c69c2d1b36__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[1eb02d62-1429-4367-a003-c8c69c2d1b36].Value" class=" form-control" type="email"
value="" maxlength="255" placeholder="exemplo@exemplo.pt" data-sc-tracking="True" data-sc-field-name="email" data-sc-field-key="E71DF40633BC4D2C824361F2937F04B2" data-val-regex="Por favor, introduza um endereço eletrónico válido."
data-val-regex-pattern="^[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,17}$" data-val-required=" " data-val="true">
<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[1eb02d62-1429-4367-a003-c8c69c2d1b36].Value" data-valmsg-replace="true"></span><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_83945cf4-446e-436b-8c2b-cee75f5ceec6" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="83945cf4-446e-436b-8c2b-cee75f5ceec6"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_83945cf4-446e-436b-8c2b-cee75f5ceec6__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[83945cf4-446e-436b-8c2b-cee75f5ceec6].ItemId" type="hidden"
value="83945cf4-446e-436b-8c2b-cee75f5ceec6"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_83945cf4-446e-436b-8c2b-cee75f5ceec6__Value" class="pt-4 bold" style="display: none;">Telefone *</label>
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_83945cf4-446e-436b-8c2b-cee75f5ceec6__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[83945cf4-446e-436b-8c2b-cee75f5ceec6].Value" class="form-control" type="text" value=""
maxlength="255" placeholder="Telefone" data-sc-tracking="True" data-sc-field-name="telefone" data-sc-field-key="616AE16E581F42228908696F1F0984D3" data-val-required=" " data-val="true" disabled="" style="display: none;"><input type="hidden"
name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[83945cf4-446e-436b-8c2b-cee75f5ceec6].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[83945cf4-446e-436b-8c2b-cee75f5ceec6].Value" data-valmsg-replace="true"></span><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0].ItemId" type="hidden"
value="a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0__Value" class="pt-4 bold">NIF *</label>
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0].Value" class="form-control" type="text" value=""
maxlength="255" placeholder="NIF" data-sc-tracking="True" data-sc-field-name="Nif" data-sc-field-key="198B12E1EE264652B61522559BF3DA08" data-val-validnif="" data-val-validnif-nif="" data-val-required=" " data-val="true">
<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[a3c2b8ce-96f8-4c28-a9a0-d821ed3805e0].Value" data-valmsg-replace="true"></span><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_cb2e37fc-2625-4d7c-86c0-02dd029057e8" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="cb2e37fc-2625-4d7c-86c0-02dd029057e8"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_cb2e37fc-2625-4d7c-86c0-02dd029057e8__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[cb2e37fc-2625-4d7c-86c0-02dd029057e8].ItemId" type="hidden"
value="cb2e37fc-2625-4d7c-86c0-02dd029057e8"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_cb2e37fc-2625-4d7c-86c0-02dd029057e8__Value" class="pt-4 bold" style="display: none;">Seguradora ou subsistema:</label>
<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[cb2e37fc-2625-4d7c-86c0-02dd029057e8].Value" data-valmsg-replace="true"></span>
<div class="form-custom-select" style="display: none;">
<div class="select-selected"></div>
<div class="select-items select-hide">
<div></div>
<div>Açoreana</div>
<div>Asisa</div>
<div>BNP Paribas Cardif</div>
<div>Cimentaçor</div>
<div>Cimpor Industria</div>
<div>Cruz Vermelha Portuguesa</div>
<div>Europ Assistance</div>
<div>Generali </div>
<div>Mudum Seguros</div>
<div>Intercement</div>
<div>LOGO</div>
<div>Lusitania</div>
<div>MGEN - Mutuelle Générale de L Education National</div>
<div>N Seguros</div>
<div>Popular Seguros</div>
<div>Real Vida Seguros</div>
<div>SAMS SBC </div>
<div>SAMS Mais Sindicato</div>
<div>Santander Totta Seguros</div>
<div>Tranquilidade</div>
<div>UNA Seguros</div>
<div>União das Misericórdias Portuguesas</div>
<div>Vitorino Seguros</div>
</div>
</div>
<select id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_cb2e37fc-2625-4d7c-86c0-02dd029057e8__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[cb2e37fc-2625-4d7c-86c0-02dd029057e8].Value" class=" form-control"
data-sc-tracking="True" data-sc-field-name="seguradora" data-sc-field-key="266022C04DCE445ABCEDB90C69552388" disabled="" style="display: none;">
<option label=" "></option>
<option value="Acoreana">Açoreana</option>
<option value="Asisa">Asisa</option>
<option value="BNP Paribas Cardif">BNP Paribas Cardif</option>
<option value="Cimentacor">Cimentaçor</option>
<option value="Cimpor Industria">Cimpor Industria</option>
<option value="Cruz Vermelha Portuguesa">Cruz Vermelha Portuguesa</option>
<option value="Europ Assistance">Europ Assistance</option>
<option value="Generali">Generali </option>
<option value="GNB - Companhia de Seguros">Mudum Seguros</option>
<option value="Intercement">Intercement</option>
<option value="LOGO">LOGO</option>
<option value="Lusitania">Lusitania</option>
<option value="MGEN">MGEN - Mutuelle Générale de L Education National</option>
<option value="N Seguros">N Seguros</option>
<option value="Popular Seguros">Popular Seguros</option>
<option value="Real Vida Seguros">Real Vida Seguros</option>
<option value="SAMS SBC">SAMS SBC </option>
<option value="SAMS SBSI">SAMS Mais Sindicato</option>
<option value="Santander Totta Seguros">Santander Totta Seguros</option>
<option value="Tranquilidade">Tranquilidade</option>
<option value="UNA">UNA Seguros</option>
<option value="Uniao das Misericordias Portuguesas">União das Misericórdias Portuguesas</option>
<option value="Vitorino Seguros">Vitorino Seguros</option>
</select><input type="hidden" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[cb2e37fc-2625-4d7c-86c0-02dd029057e8].Required" value="false" data-sc-conditions-required="">
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_262d11ab-58ef-45f8-88c6-1827ec65f0fe" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="262d11ab-58ef-45f8-88c6-1827ec65f0fe"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_262d11ab-58ef-45f8-88c6-1827ec65f0fe__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[262d11ab-58ef-45f8-88c6-1827ec65f0fe].ItemId" type="hidden"
value="262d11ab-58ef-45f8-88c6-1827ec65f0fe"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_262d11ab-58ef-45f8-88c6-1827ec65f0fe__Value" class="pt-4 bold" style="display: none;">Número do cartão do seguro de saúde/plano de
benefícios:</label>
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_262d11ab-58ef-45f8-88c6-1827ec65f0fe__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[262d11ab-58ef-45f8-88c6-1827ec65f0fe].Value" class=" form-control" type="text"
value="" maxlength="255" placeholder="Número do cartão do seguro de saúde/plano de benefícios" data-sc-tracking="True" data-sc-field-name="planobeneficios" data-sc-field-key="798F47E3289E4BA6A75E4479FA7A1578" disabled=""
style="display: none;"><input type="hidden" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[262d11ab-58ef-45f8-88c6-1827ec65f0fe].Required" value="false" data-sc-conditions-required="">
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<p data-sc-field-key="5EB22E0EF2954B4993FF7253906F0C86" class="" style="display: none;"> Número que consta na frente do cartão do seu seguro de saúde/plano de benefícios.</p><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_eb7f4dba-258c-46ac-ae54-25ef42ae3cb9" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="eb7f4dba-258c-46ac-ae54-25ef42ae3cb9"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_eb7f4dba-258c-46ac-ae54-25ef42ae3cb9__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[eb7f4dba-258c-46ac-ae54-25ef42ae3cb9].ItemId" type="hidden"
value="eb7f4dba-258c-46ac-ae54-25ef42ae3cb9"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_eb7f4dba-258c-46ac-ae54-25ef42ae3cb9__Value" class="pt-4 bold">Nº voucher *</label>
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_eb7f4dba-258c-46ac-ae54-25ef42ae3cb9__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[eb7f4dba-258c-46ac-ae54-25ef42ae3cb9].Value" class=" form-control" type="text"
value="" maxlength="255" placeholder="Nº voucher" data-sc-tracking="True" data-sc-field-name="voucher" data-sc-field-key="B7FAF7DF286A4BF49E0E746D57AC76AE" data-val-required=" " data-val="true">
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id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_a534bbd7-fcf7-4449-b88b-f41431a662fb" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="a534bbd7-fcf7-4449-b88b-f41431a662fb"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_a534bbd7-fcf7-4449-b88b-f41431a662fb__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[a534bbd7-fcf7-4449-b88b-f41431a662fb].ItemId" type="hidden"
value="a534bbd7-fcf7-4449-b88b-f41431a662fb"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_a534bbd7-fcf7-4449-b88b-f41431a662fb__Value" class="pt-4 bold" style="display: none;">Nº voucher</label>
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_a534bbd7-fcf7-4449-b88b-f41431a662fb__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[a534bbd7-fcf7-4449-b88b-f41431a662fb].Value" class="form-control" type="text" value=""
maxlength="255" placeholder="Nº voucher" data-sc-tracking="True" data-sc-field-name="voucher_facultativo" data-sc-field-key="B8F8D619C09B484A83C747439D25413B" disabled="" style="display: none;"><input type="hidden"
name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[a534bbd7-fcf7-4449-b88b-f41431a662fb].Required" value="false" data-sc-conditions-required="">
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id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_Index_3223e4aa-60a1-48a2-8835-1f210e969cc4" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields.Index" type="hidden" value="3223e4aa-60a1-48a2-8835-1f210e969cc4"><input
id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_3223e4aa-60a1-48a2-8835-1f210e969cc4__ItemId" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[3223e4aa-60a1-48a2-8835-1f210e969cc4].ItemId" type="hidden"
value="3223e4aa-60a1-48a2-8835-1f210e969cc4"><label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_3223e4aa-60a1-48a2-8835-1f210e969cc4__Value" class="pt-4 bold">Mensagem *</label>
<textarea id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_3223e4aa-60a1-48a2-8835-1f210e969cc4__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[3223e4aa-60a1-48a2-8835-1f210e969cc4].Value" class=" form-control" rows="6"
maxlength="1000" placeholder="Descreva de forma detalhada o motivo do seu contacto" data-sc-tracking="True" data-sc-field-name="mensagem" data-sc-field-key="59F17E221C954FC3BA34DF2495ED7650" data-val-required=" " data-val="true"></textarea>
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<div data-sc-field-key="AABCFC0F25EB43298728C084E488D8B6" class="pt-4">
<h6 data-sc-field-key="2559A7AE1D5D47D8A99D20FD2C839995" class="bold pt-3 pb-3">Caso pretenda poderá adicionar aqui documentos úteis à sua exposição</h6><input
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value="e147011a-93f5-4f9e-b595-2f9dfe01f1c6">
<div class="form-file-upload file-drag pt-4">
<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[e147011a-93f5-4f9e-b595-2f9dfe01f1c6].Files" data-valmsg-replace="true"></span>
<label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_e147011a-93f5-4f9e-b595-2f9dfe01f1c6__Files" class="adv-upload">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_e147011a-93f5-4f9e-b595-2f9dfe01f1c6__Files" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[e147011a-93f5-4f9e-b595-2f9dfe01f1c6].Files" class="file-drag pt-4" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="File Upload" data-sc-field-key="BEF505C59B694329A0E2D77A81090A46" data-val-filesize="Tamanho do ficheiro incorrecto." data-val-filesize-max="10485760"
data-val-filetype="Por favor introduza um ficheiro com extensão válida." data-val-filetype-allowedcontenttypes=".pdf,.jpg,.tif,.png,.gif,.bmp,.doc,.docx,.msg,.xls,.xlsx,.txt" data-val="true"><button
class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="98B9536840A94966BB475C043CCFEDCB" class="small">Os ficheiros a carregar devem ter até 10MB, tendo em atenção o seu formato e qualidade ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de
dispositivo móvel confira, nas definições, as permissões de acesso à câmera e galeria de imagens.</p>
</div>
<p data-sc-field-key="CF73A3DF68DF4DE2B98A6BBAF50A35C4" class="pt-4">(*) campos de preenchimento obrigatório, sob pena de não ser possível finalizar a submissão do pedido</p><input
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<input type="checkbox" id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_784c7642-ed4e-4b0c-a0d0-2c20384290e9__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[784c7642-ed4e-4b0c-a0d0-2c20384290e9].Value" class="" value="true"
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<label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_784c7642-ed4e-4b0c-a0d0-2c20384290e9__Value"></label>
<input type="hidden" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[784c7642-ed4e-4b0c-a0d0-2c20384290e9].Value" value="false">
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<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[784c7642-ed4e-4b0c-a0d0-2c20384290e9].Value" data-valmsg-replace="true"></span>
<span data-sc-field-key="4E1B3B907D2D4A9D8803436F40CCD30C" class="form-field--text "> Declaro que li e aceito os
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/termos-condicoes-formularios">termos e condições</a> apresentados *</span><input
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value="b1ce2c16-18cb-4b4b-ba6d-cc3766a7ec27">
<div class="">
<input type="checkbox" id="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_b1ce2c16-18cb-4b4b-ba6d-cc3766a7ec27__Value" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[b1ce2c16-18cb-4b4b-ba6d-cc3766a7ec27].Value" class="" value="true"
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<label for="fxb_e06b6231-b45b-461e-8e8d-639346bc4be9_Fields_b1ce2c16-18cb-4b4b-ba6d-cc3766a7ec27__Value"></label>
<input type="hidden" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[b1ce2c16-18cb-4b4b-ba6d-cc3766a7ec27].Value" value="false">
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<span class="field-validation-valid" data-valmsg-for="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.Fields[b1ce2c16-18cb-4b4b-ba6d-cc3766a7ec27].Value" data-valmsg-replace="true"></span>
<span data-sc-field-key="3A3D602570D44DD593DBFF8E72D4EFA2" class="form-field--text "> Declaro que li e aceito a
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/protecao-de-dados-pessoais">política de tratamento de dados pessoais</a> AdvanceCare *</span>
<div data-sc-field-key="830CDC3741974962AF6F79019A9A7C88" class="modal">
<div data-sc-field-key="DA1E456DF1D84B79A5B6670759414832" class="modal-dialog">
<div data-sc-field-key="EFCD37FBBE2947D6A56B6E58B6793434" class="modal-content p-4">
<div data-sc-field-key="7D1167BCB2D743D58D2CCC3889F78CCC" class="modal-header-block pt-5 ">
<div data-sc-field-key="F1C287E916B84279A9BA9433FA088E90" class="modal-title">
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
<h3 data-sc-field-key="F7E2ED068568446B8F8D0F367FCC99DB" class="text-center">Formulário enviado com sucesso!</h3><br>
</div>
</div>
</div>
</div>
</div>
<div data-sc-field-key="3BB8ADA8D6494579B474FA4F4D6A5A25" class="pt-5 text-center">
<input value="Enviar" type="submit" class="btn btn-primary modal-form send" name="fxb.e06b6231-b45b-461e-8e8d-639346bc4be9.12583474-ad1e-41e5-bd4b-55adda2461c2" data-sc-field-key="2CC67C10628C434B9C8DBFBDD72E09EF" disabled="">
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</div>
</div>
</div>
<input type="hidden" data-name="loja-online" data-friend-name="Loja online" data-sc-fxb-condition="" value="{
"fieldConditions": [
{
"matchType": "any",
"conditions": [
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"actions": [
{
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"actionType": "show",
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},
{
"matchType": "any",
"conditions": [
{
"fieldId": "BF85DE30FF5340358760F4BC6290865D",
"operator": "is equal to",
"value": "Cancelamento de compras"
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<div data-sc-field-key="27A746B07FC74D7A84C58E2FB327087D" class="row">
<div data-sc-field-key="4E4DFB696B7B4532A27BAD5848460D30" class="col-lg-12 col-sm-12">
<label data-sc-field-key="A1BF113B9D494B7B8B1E9CE16418E928" class="">Para outros assuntos não relacionados com o tema selecionado, utilize a nossa plataforma myAdvanceCare ou contacte-nos pelos canais alternativos disponíveis no verso do seu
cartão. Pedidos de reembolso por esta via não são aceites.</label>
<span data-sc-field-key="504ED376AAEE48099E77CBDCC4CBC766" class="form-field--text pt-5"> Na utilização deste formulário o utilizador deve tomar conhecimento das seguintes disposições uma vez que é solicitado que forneça previamente dados
pessoais. A AdvanceCare S.A é a responsável pelo tratamento dos dados recolhidos neste formulário. Os contactos do responsável e do encarregado da proteção de dados estão disponíveis .</span>
<span data-sc-field-key="2064D72CE3B24F18ADBBE3A9BDFE5FF3" class="form-field--text "> Os dados recolhidos destinam-se à análise do pedido e atualização de dados. O fundamento jurídico para o tratamento é a necessidade de realização de
diligências contratuais solicitadas. Para mais detalhe consulte <a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/protecao-de-dados-pessoais">aqui</a>.</span>
<span data-sc-field-key="A6E90B9E46644C2BB725A885CE4CA2C7" class="form-field--text "> O titular dos dados poderá, em qualquer momento, exercer os direitos, veja mais detalhe
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/formularios/gestao-de-dados-pessoais">aqui</a>.</span>
<h3 data-sc-field-key="DBFC89265A1A49EB8DF920C0E1B492B7" class="pt-3">Por favor preencha os seguintes dados:</h3><input id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_Index_9053ce72-599b-4a93-9957-c7ef53c18103"
name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields.Index" type="hidden" value="9053ce72-599b-4a93-9957-c7ef53c18103"><input id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_9053ce72-599b-4a93-9957-c7ef53c18103__ItemId"
name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[9053ce72-599b-4a93-9957-c7ef53c18103].ItemId" type="hidden" value="9053ce72-599b-4a93-9957-c7ef53c18103"><label
for="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_9053ce72-599b-4a93-9957-c7ef53c18103__Value" class="pt-4 bold">Nome *</label>
<input id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_9053ce72-599b-4a93-9957-c7ef53c18103__Value" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[9053ce72-599b-4a93-9957-c7ef53c18103].Value" class="form-control" type="text" value=""
maxlength="255" placeholder="Nome" data-sc-tracking="True" data-sc-field-name="nome" data-sc-field-key="6DF7EE52E507450EBC46241331BE206E" data-val-required=" " data-val="true">
<span class="field-validation-valid" data-valmsg-for="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[9053ce72-599b-4a93-9957-c7ef53c18103].Value" data-valmsg-replace="true"></span><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_Index_eb15e5a8-4a53-447c-afce-bf0b7b82c715" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields.Index" type="hidden" value="eb15e5a8-4a53-447c-afce-bf0b7b82c715"><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_eb15e5a8-4a53-447c-afce-bf0b7b82c715__ItemId" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[eb15e5a8-4a53-447c-afce-bf0b7b82c715].ItemId" type="hidden"
value="eb15e5a8-4a53-447c-afce-bf0b7b82c715"><label for="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_eb15e5a8-4a53-447c-afce-bf0b7b82c715__Value" class="pt-4 bold">E-mail *</label>
<input id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_eb15e5a8-4a53-447c-afce-bf0b7b82c715__Value" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[eb15e5a8-4a53-447c-afce-bf0b7b82c715].Value" class="form-control" type="email"
value="" maxlength="255" placeholder="exemplo@exemplo.pt" data-sc-tracking="True" data-sc-field-name="Email" data-sc-field-key="9017117D58E64AF1B5BC59059AA21539" data-val-regex="Por favor, introduza um endereço eletrónico válido."
data-val-regex-pattern="^[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,17}$" data-val-required=" " data-val="true">
<span class="field-validation-valid" data-valmsg-for="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[eb15e5a8-4a53-447c-afce-bf0b7b82c715].Value" data-valmsg-replace="true"></span><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_Index_24640a42-6ff8-4cf6-b854-e6b07c55a3c0" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields.Index" type="hidden" value="24640a42-6ff8-4cf6-b854-e6b07c55a3c0"><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_24640a42-6ff8-4cf6-b854-e6b07c55a3c0__ItemId" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[24640a42-6ff8-4cf6-b854-e6b07c55a3c0].ItemId" type="hidden"
value="24640a42-6ff8-4cf6-b854-e6b07c55a3c0"><label for="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_24640a42-6ff8-4cf6-b854-e6b07c55a3c0__Value" class="pt-4 bold">NIF</label>
<input id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_24640a42-6ff8-4cf6-b854-e6b07c55a3c0__Value" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[24640a42-6ff8-4cf6-b854-e6b07c55a3c0].Value" class="form-control" type="text" value=""
maxlength="255" placeholder="NIF" data-sc-tracking="True" data-sc-field-name="Single-Line Text(2)" data-sc-field-key="C87B9DAE8AD94EBF87DC3C9DC577C3A5" data-val-validnif="" data-val-validnif-nif="" data-val="true">
<span class="field-validation-valid" data-valmsg-for="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[24640a42-6ff8-4cf6-b854-e6b07c55a3c0].Value" data-valmsg-replace="true"></span><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_Index_9ead6a10-7cae-4bee-9b04-94d05c1cfc39" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields.Index" type="hidden" value="9ead6a10-7cae-4bee-9b04-94d05c1cfc39"><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_9ead6a10-7cae-4bee-9b04-94d05c1cfc39__ItemId" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[9ead6a10-7cae-4bee-9b04-94d05c1cfc39].ItemId" type="hidden"
value="9ead6a10-7cae-4bee-9b04-94d05c1cfc39"><label for="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_9ead6a10-7cae-4bee-9b04-94d05c1cfc39__Value" class="pt-4 bold">Seguradora ou subsistema:</label>
<span class="field-validation-valid" data-valmsg-for="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[9ead6a10-7cae-4bee-9b04-94d05c1cfc39].Value" data-valmsg-replace="true"></span>
<div class="form-custom-select">
<div class="select-selected"></div>
<div class="select-items select-hide">
<div></div>
<div>Açoreana</div>
<div>Asisa</div>
<div>BNP Paribas Cardif</div>
<div>Cimentacor</div>
<div>Cimpor Industria</div>
<div>Cruz Vermelha Portuguesa</div>
<div>Europ Assistance</div>
<div>Generali</div>
<div>GNB - Companhia de Seguros</div>
<div>Intercement</div>
<div>LOGO</div>
<div>Lusitania</div>
<div>MGEN</div>
<div>N Seguros</div>
<div>Popular Seguros</div>
<div>Real Vida Seguros</div>
<div>SAMS SBC</div>
<div>SAMS SBSI</div>
<div>Santander Totta Seguros</div>
<div>Tranquilidade</div>
<div>UNA</div>
<div>Uniao das Misericordias Portuguesas</div>
<div>Vitorino Seguros</div>
</div>
</div>
<select id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_9ead6a10-7cae-4bee-9b04-94d05c1cfc39__Value" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[9ead6a10-7cae-4bee-9b04-94d05c1cfc39].Value" class="form-control"
data-sc-tracking="True" data-sc-field-name="Dropdown List" data-sc-field-key="155F44643C2A4AD79641A18C62973D32">
<option label=" "></option>
<option value="Acoreana">Açoreana</option>
<option value="Asisa">Asisa</option>
<option value="BNP Paribas Cardif">BNP Paribas Cardif</option>
<option value="Cimentacor">Cimentacor</option>
<option value="Cimpor Industria">Cimpor Industria</option>
<option value="Cruz Vermelha Portuguesa">Cruz Vermelha Portuguesa</option>
<option value="Europ Assistance">Europ Assistance</option>
<option value="Generali">Generali</option>
<option value="GNB - Companhia de Seguros">GNB - Companhia de Seguros</option>
<option value="Intercement">Intercement</option>
<option value="LOGO">LOGO</option>
<option value="Lusitania">Lusitania</option>
<option value="MGEN">MGEN</option>
<option value="N Seguros">N Seguros</option>
<option value="Popular Seguros">Popular Seguros</option>
<option value="Real Vida Seguros">Real Vida Seguros</option>
<option value="SAMS SBC">SAMS SBC</option>
<option value="SAMS SBSI">SAMS SBSI</option>
<option value="Santander Totta Seguros">Santander Totta Seguros</option>
<option value="Tranquilidade">Tranquilidade</option>
<option value="UNA">UNA</option>
<option value="Uniao das Misericordias Portuguesas">Uniao das Misericordias Portuguesas</option>
<option value="Vitorino Seguros">Vitorino Seguros</option>
</select>
<input id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_Index_49312b24-6165-42d0-8ea0-b3b58f8360b0" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields.Index" type="hidden" value="49312b24-6165-42d0-8ea0-b3b58f8360b0"><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_49312b24-6165-42d0-8ea0-b3b58f8360b0__ItemId" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[49312b24-6165-42d0-8ea0-b3b58f8360b0].ItemId" type="hidden"
value="49312b24-6165-42d0-8ea0-b3b58f8360b0"><label for="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_49312b24-6165-42d0-8ea0-b3b58f8360b0__Value" class="pt-4 bold">Nº do cartao do seguro de saúde / plano de benefícios:</label>
<input id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_49312b24-6165-42d0-8ea0-b3b58f8360b0__Value" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[49312b24-6165-42d0-8ea0-b3b58f8360b0].Value" class="form-control" type="text" value=""
maxlength="255" placeholder="Nº do cartao do seguro de saúde / plano de benefícios (Número que consta na frente do cartão do seu seguro de saúde/plano de benefícios.)" data-sc-tracking="True" data-sc-field-name="Single-Line Text(3)"
data-sc-field-key="F4E0591EA4CD438EA5D7CBB2441279EB">
<span class="field-validation-valid" data-valmsg-for="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[49312b24-6165-42d0-8ea0-b3b58f8360b0].Value" data-valmsg-replace="true"></span>
<p data-sc-field-key="18674A25B7B1478BB97FB7A82A497489" class=""> Número que consta na frente do cartão do seu seguro de saúde/plano de benefícios.</p><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_Index_8275a3db-57ae-468c-a9dd-b8862f9d7d2a" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields.Index" type="hidden" value="8275a3db-57ae-468c-a9dd-b8862f9d7d2a"><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_8275a3db-57ae-468c-a9dd-b8862f9d7d2a__ItemId" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[8275a3db-57ae-468c-a9dd-b8862f9d7d2a].ItemId" type="hidden"
value="8275a3db-57ae-468c-a9dd-b8862f9d7d2a"><label for="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_8275a3db-57ae-468c-a9dd-b8862f9d7d2a__Value" class="pt-4 bold">Mensagem *</label>
<textarea id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_8275a3db-57ae-468c-a9dd-b8862f9d7d2a__Value" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[8275a3db-57ae-468c-a9dd-b8862f9d7d2a].Value" class="form-control" rows="6"
maxlength="1000" placeholder="Descreva de forma detalhada o motivo do seu contacto" data-sc-tracking="True" data-sc-field-name="mensagem" data-sc-field-key="48339F67FA034B16B5F02B1009FDA1ED" data-val-required=" " data-val="true"></textarea>
<span class="field-validation-valid" data-valmsg-for="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[8275a3db-57ae-468c-a9dd-b8862f9d7d2a].Value" data-valmsg-replace="true"></span>
<div data-sc-field-key="D18DAD6F5EDF47E3AACD4DEEF24D190A" class="pt-4">
<h6 data-sc-field-key="120CF556FA804D00ADE0AD808EE1CF12" class="bold pt-3 pb-3">Caso pretenda poderá adicionar aqui documentos úteis à sua exposição:</h6><input
id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_Index_5c479b26-5e2c-41cf-99f4-44597cb29a05" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields.Index" type="hidden" value="5c479b26-5e2c-41cf-99f4-44597cb29a05"><input
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value="5c479b26-5e2c-41cf-99f4-44597cb29a05">
<div class="form-file-upload file-drag">
<span class="field-validation-valid" data-valmsg-for="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[5c479b26-5e2c-41cf-99f4-44597cb29a05].Files" data-valmsg-replace="true"></span>
<label for="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_5c479b26-5e2c-41cf-99f4-44597cb29a05__Files" class="">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_660ad6ad-204e-4978-94e6-13847c0a1af9_Fields_5c479b26-5e2c-41cf-99f4-44597cb29a05__Files" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[5c479b26-5e2c-41cf-99f4-44597cb29a05].Files" class="file-drag" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="File Upload" data-sc-field-key="5650D51F88F140D6BD6459641D680E85" data-val-filesize="Tamanho do ficheiro incorrecto." data-val-filesize-max="10485760"
data-val-filetype="Por favor introduza um ficheiro com extensão válida." data-val-filetype-allowedcontenttypes=".pdf,.jpg,.tif,.png,.gif,.bmp,.doc,.docx,.msg,.xls,.xlsx,.txt" data-val="true"><button
class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="4DAC0426EAFF43C488C098D1DEFB5D48" class="small">Arraste para este espaço os ficheiros a carregar até 10MB, tendo em atenção o seu formato e qualidade (PDF, JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT). Em
caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens.)</p>
</div>
<p data-sc-field-key="30DCB0B129A742A9ACF5ABB5A31FF6FA" class="pt-4">(*) Campos de preenchimento obrigatório, sob pena de não ser possível finalizar a submissão do pedido.</p><input
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<span data-sc-field-key="18E383A0C2954FDEBC63B7E2CB5373CF" class="form-field--text "> Declaro que li e aceito os
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/termos-condicoes-formularios">termos e condições</a> apresentados *</span><input
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<input type="hidden" name="fxb.660ad6ad-204e-4978-94e6-13847c0a1af9.Fields[21000cc8-c6e0-40bb-a788-0662dc60ed2b].Value" value="false">
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<span data-sc-field-key="1A8B02EC0530468D872FEBE947984ADA" class="form-field--text "> Declaro que li e aceito a
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/protecao-de-dados-pessoais">política de tratamento de dados pessoais</a> AdvanceCare *</span>
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<div data-sc-field-key="51AB623182684122BDCD430F812AF832" class="modal-dialog">
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<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
<h3 data-sc-field-key="6CF97A06263D479EB43D42ED9CCA69A5" class="text-center">Formulário enviado com sucesso!</h3><br>
</div>
</div>
</div>
</div>
</div>
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<div data-sc-field-key="5AD87DD6CDB246C982FACD9CD7935BFC" class="">
<div data-sc-field-key="6E0876AB860549B0AA77923B2575FCFA" class="">
<p data-sc-field-key="0B451124C9B44050899C3E0EEE461755" class="">Para outros assuntos não relacionados com o tema selecionado, utilize a nossa plataforma myAdvanceCare ou contacte-nos pelos canais alternativos disponíveis no verso do seu
cartão. Pedidos de reembolso por esta via não são aceites.</p>
<span data-sc-field-key="20161BB895F64156946C46AF7729BBDA" class="form-field--text pt-5"> Com o objetivo de melhorar a qualidade dos serviços prestados e com o intuito de promover a melhoria contínua dos nossos serviços, a AdvanceCare, entidade
certificada pelos referenciais da Qualidade NP EN ISO 9001 e NP ISO 10002, disponibiliza através do seu portal um formulário de submissão de pedidos no âmbito de Processos de Autorizações Clínicas. Na utilização deste formulário o utilizador
deve tomar conhecimento das seguintes disposições uma vez que é solicitado que forneça previamente dados pessoais. A AdvanceCare S.A é uma entidade subcontratada pela seguradora/entidade para a gestão do seguro/plano. Os dados são recolhidos
para a gestão do pedido de autorização clinica e atualização dos seus dados. O fundamento jurídico para o tratamento pela AdvanceCare é a execução enquanto subcontratante das diligências para resposta ao contrato com a seguradora/entidade na
gestão de seguros/planos de saúde. Para mais detalhe consulte <a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/protecao-de-dados-pessoais">aqui</a>. O titular dos dados
deverá exercer os seus direitos junto da sua seguradora/entidade.</span><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_1b31dfeb-af96-4734-853e-6af5dcaa938a" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index"
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<div class="form-custom-select">
<div class="select-selected">Nova submissão de pedido de pre-autorização clínica</div>
<div class="select-items select-hide">
<div></div>
<div>Nova submissão de pedido de pre-autorização clínica</div>
<div>Pedido de reavaliação do processo clínico</div>
<div>Estado do processo</div>
</div>
</div>
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<option label=" "></option>
<option value="Nova submissão de pedido de pre-autorização clínica" selected="selected">Nova submissão de pedido de pre-autorização clínica</option>
<option value="Pedido de reavaliação do processo clínico">Pedido de reavaliação do processo clínico</option>
<option value="Estado do processo ">Estado do processo</option>
</select>
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<div class="form-custom-select">
<div class="select-selected">Segurado / Utente / Beneficiário / Representante</div>
<div class="select-items select-hide">
<div></div>
<div>Segurado / Utente / Beneficiário / Representante</div>
<div>Prestador Convencionado </div>
<div>Prestador não convencionado </div>
</div>
</div>
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data-sc-tracking="True" data-sc-field-name="tipoutilizador" data-sc-field-key="FFF4E18EEE304059879DC217A1A21649" data-val-required=" " data-val="true">
<option label=" "></option>
<option value="Segurado / Utente / Beneficiário / Representante" selected="selected">Segurado / Utente / Beneficiário / Representante</option>
<option value="Prestador Convencionado ">Prestador Convencionado </option>
<option value="Prestador não convencionado ">Prestador não convencionado </option>
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<div class="form-custom-select">
<div class="select-selected"></div>
<div class="select-items select-hide">
<div></div>
<div>Açoreana</div>
<div>Asisa</div>
<div>BIC seguros </div>
<div>BNP Paribas Cardif</div>
<div>Cimentaçor</div>
<div>Cimpor Industria</div>
<div>Cruz Vermelha Portuguesa</div>
<div>Ensa Seguros</div>
<div>Europ Assistance </div>
<div>Generali </div>
<div>Mudum Seguros</div>
<div>Intercement</div>
<div>LOGO</div>
<div>Lusitania</div>
<div>MGEN - Mutuelle Générale de L Education National</div>
<div>N Seguros</div>
<div>Nossa - PT</div>
<div>Popular Seguros</div>
<div>Real Vida Seguros</div>
<div>SAMS SBC </div>
<div>SAMS Mais Sindicato</div>
<div>Santander Totta Seguros</div>
<div>Tranquilidade</div>
<div>UNA Seguros</div>
<div>União das Misericórdias Portuguesas</div>
</div>
</div>
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data-sc-tracking="True" data-sc-field-name="SeguradoraSubsistema" data-sc-field-key="470B5550C7C8434B91E21F7B1C183853" data-val-required=" " data-val="true">
<option label=" "></option>
<option value="Açoreana">Açoreana</option>
<option value="Asisa">Asisa</option>
<option value="BIC seguros ">BIC seguros </option>
<option value="BNP Paribas Cardif">BNP Paribas Cardif</option>
<option value="Cimentaçor">Cimentaçor</option>
<option value="Cimpor Industria">Cimpor Industria</option>
<option value="Cruz Vermelha Portuguesa">Cruz Vermelha Portuguesa</option>
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<option value="Europ Assistance">Europ Assistance </option>
<option value="Generali ">Generali </option>
<option value="Mudum Seguros">Mudum Seguros</option>
<option value="Intercement">Intercement</option>
<option value="LOGO">LOGO</option>
<option value="Lusitania">Lusitania</option>
<option value="MGEN - Mutuelle Générale de L Education National">MGEN - Mutuelle Générale de L Education National</option>
<option value="N Seguros">N Seguros</option>
<option value="Nossa - PT">Nossa - PT</option>
<option value="Popular Seguros">Popular Seguros</option>
<option value="Real Vida Seguros">Real Vida Seguros</option>
<option value="SAMS SBC">SAMS SBC </option>
<option value="SAMS Mais Sindicato">SAMS Mais Sindicato</option>
<option value="Santander Totta Seguros">Santander Totta Seguros</option>
<option value="Tranquilidade">Tranquilidade</option>
<option value="UNA Seguros">UNA Seguros</option>
<option value="União das Misericórdias Portuguesas">União das Misericórdias Portuguesas</option>
</select>
<h6 data-sc-field-key="F03152CD8C7947FDAD3844F46B1D2F6F" class="pt-4" style="display: none;">Dados do prestador</h6>
<div data-sc-field-key="0D68B7B87FD5468987E3147C31FADF6E" class="pt-4" style="display: none;">
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_33c1f306-95df-4f5d-9210-bf851d66c863" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="33c1f306-95df-4f5d-9210-bf851d66c863"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_33c1f306-95df-4f5d-9210-bf851d66c863__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[33c1f306-95df-4f5d-9210-bf851d66c863].ItemId" type="hidden"
value="33c1f306-95df-4f5d-9210-bf851d66c863"><label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_33c1f306-95df-4f5d-9210-bf851d66c863__Value" class="pt-4 bold" style="display: none;">Tem acesso à funcionalidade de pic web?</label>
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[33c1f306-95df-4f5d-9210-bf851d66c863].Value" data-valmsg-replace="true"></span>
<div class="form-custom-select" style="display: none;">
<div class="select-selected select-arrow-active"></div>
<div class="select-items">
<div></div>
<div>Sim</div>
<div>Não</div>
<div>Sim, contudo encontra-se indisponível</div>
</div>
</div>
<select id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_33c1f306-95df-4f5d-9210-bf851d66c863__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[33c1f306-95df-4f5d-9210-bf851d66c863].Value" class="form-control"
data-sc-tracking="True" data-sc-field-name="picweb" data-sc-field-key="EE4A9F3EBA8B438C82E09ACDB898C4BC" data-val-required=" " data-val="true" disabled="" style="display: none;">
<option label=" "></option>
<option value="Sim">Sim</option>
<option value="Não">Não</option>
<option value="Sim, contudo encontra-se indisponível">Sim, contudo encontra-se indisponível</option>
</select><input type="hidden" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[33c1f306-95df-4f5d-9210-bf851d66c863].Required" value="false" data-sc-conditions-required="">
<br>
<span data-sc-field-key="88578FFCF82B409A9F896F98B909CD4D" class="form-field--text bold" style="display: none;"> Por favor vá directamente ao
<a class="form-field-link" target="blank" href="https://profissional.advancecare.com/cas/login?service=https%3A%2F%2Fprofissional.advancecare.com%2FzonaReservadaApi%2Fj_spring_cas_security_check">Pic Web</a>.</span>
</div>
<div data-sc-field-key="6B404416437B4C3A9AE20D19A0055D82" class="" style="display: none;">
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_ce6a0f6f-7b36-4050-aa64-efdf6605bb4d" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="ce6a0f6f-7b36-4050-aa64-efdf6605bb4d"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_ce6a0f6f-7b36-4050-aa64-efdf6605bb4d__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[ce6a0f6f-7b36-4050-aa64-efdf6605bb4d].ItemId" type="hidden"
value="ce6a0f6f-7b36-4050-aa64-efdf6605bb4d"><label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_ce6a0f6f-7b36-4050-aa64-efdf6605bb4d__Value" class="pt-4 bold">Designação social *</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_ce6a0f6f-7b36-4050-aa64-efdf6605bb4d__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[ce6a0f6f-7b36-4050-aa64-efdf6605bb4d].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Designação social" data-sc-tracking="True" data-sc-field-name="prestadordesignacaosocial" data-sc-field-key="BE2F49849EDF408F953113EEA2C79D27" data-val-required=" " data-val="true"><input type="hidden"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[ce6a0f6f-7b36-4050-aa64-efdf6605bb4d].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[ce6a0f6f-7b36-4050-aa64-efdf6605bb4d].Value" data-valmsg-replace="true"></span><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8].ItemId" type="hidden"
value="3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8"><label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8__Value" class="pt-4 bold">Identificação (CIF/Cédula) *</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Identificação (CIF/Cedula)" data-sc-tracking="True" data-sc-field-name="prestadorcifcedula" data-sc-field-key="9516C4F864ED4AC1B59B4D27B7D5E738" data-val-required=" " data-val="true"><input
type="hidden" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[3c5070c4-b7ce-4a4c-b1b2-19f8dd717cb8].Value" data-valmsg-replace="true"></span><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_926b29a0-faf7-41c6-b560-22733fd79d2f" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="926b29a0-faf7-41c6-b560-22733fd79d2f"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_926b29a0-faf7-41c6-b560-22733fd79d2f__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[926b29a0-faf7-41c6-b560-22733fd79d2f].ItemId" type="hidden"
value="926b29a0-faf7-41c6-b560-22733fd79d2f"><label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_926b29a0-faf7-41c6-b560-22733fd79d2f__Value" class="pt-4 bold">Morada *</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_926b29a0-faf7-41c6-b560-22733fd79d2f__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[926b29a0-faf7-41c6-b560-22733fd79d2f].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Morada " data-sc-tracking="True" data-sc-field-name="prestadormorada" data-sc-field-key="B82A0CB348084A0A8ABCC07B5B38B90E" data-val-required=" " data-val="true"><input type="hidden"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[926b29a0-faf7-41c6-b560-22733fd79d2f].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[926b29a0-faf7-41c6-b560-22733fd79d2f].Value" data-valmsg-replace="true"></span>
</div>
<div data-sc-field-key="4C1D4F1754DB4A338214EC25F6885896" class="pt-4">
<h6 data-sc-field-key="8BF5219FBE8A4AB3B9209D1CEAE72ED4" class="pt-3">Dados do segurado</h6><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba"><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba__ItemId"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba].ItemId" type="hidden" value="97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba"><label
for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba__Value" class="pt-4 bold">Nº cartão do seguro de saúde / plano de benefícios *</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Nº cartão do seguro de saúde / plano de benefícios" data-sc-tracking="True" data-sc-field-name="cartaosaude" data-sc-field-key="5432CCD6390648DEA7026D2123CA2152" data-val-required=" "
data-val="true"><input type="hidden" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[97fbd58b-16cb-48ac-bd9d-b7d8c7fcbbba].Value" data-valmsg-replace="true"></span><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_84dece49-a94f-4c17-864a-5c1421454768" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="84dece49-a94f-4c17-864a-5c1421454768"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_84dece49-a94f-4c17-864a-5c1421454768__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[84dece49-a94f-4c17-864a-5c1421454768].ItemId" type="hidden"
value="84dece49-a94f-4c17-864a-5c1421454768"><label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_84dece49-a94f-4c17-864a-5c1421454768__Value" class="pt-4 bold">Nome *</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_84dece49-a94f-4c17-864a-5c1421454768__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[84dece49-a94f-4c17-864a-5c1421454768].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Nome" data-sc-tracking="True" data-sc-field-name="nome" data-sc-field-key="1D2370B5DEDF421E9C051FFE102C6D4F" data-val-required=" " data-val="true"><input type="hidden"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[84dece49-a94f-4c17-864a-5c1421454768].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[84dece49-a94f-4c17-864a-5c1421454768].Value" data-valmsg-replace="true"></span><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb].ItemId" type="hidden"
value="979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb"><label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb__Value" class="pt-4 bold">Telemóvel</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb].Value" class="form-control" type="text"
value="" maxlength="255" placeholder="Telemóvel" data-sc-tracking="True" data-sc-field-name="telemovel" data-sc-field-key="9949168C437F46FC9AFB9CA6CC87A0B4"><input type="hidden"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[979e2223-c9d6-4b96-9ce1-0f55c7aa9bbb].Value" data-valmsg-replace="true"></span>
</div>
<div data-sc-field-key="CC26BB6E8C6B432C9F555B2BB9B6840D" class="pt-4">
<h6 data-sc-field-key="C640A4041CA8413E9700A4D19A4F3F77" class="pt-3">Email de contacto</h6><label data-sc-field-key="6C9CEDD74D1B4AAFA99D84B6C44BE42E" class="pt-4 bold" style="display: none;">Email Prestador</label><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_8e2d43f7-48fd-4bcf-8128-c49061731ab6" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="8e2d43f7-48fd-4bcf-8128-c49061731ab6"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_8e2d43f7-48fd-4bcf-8128-c49061731ab6__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[8e2d43f7-48fd-4bcf-8128-c49061731ab6].ItemId" type="hidden"
value="8e2d43f7-48fd-4bcf-8128-c49061731ab6"><label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_8e2d43f7-48fd-4bcf-8128-c49061731ab6__Value" class="pt-4 bold"></label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_8e2d43f7-48fd-4bcf-8128-c49061731ab6__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[8e2d43f7-48fd-4bcf-8128-c49061731ab6].Value" class="form-control" type="email"
value="" maxlength="255" placeholder="exemplo@exemplo.pt" data-sc-tracking="True" data-sc-field-name="Email_notificacao_tipo de Utilizador" data-sc-field-key="828D21557BCF4247BBA063C249DB3611"
data-val-regex="Por favor, introduza um endereço eletrónico válido." data-val-regex-pattern="^[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,17}$" data-val-required=" " data-val="true"><input type="hidden"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[8e2d43f7-48fd-4bcf-8128-c49061731ab6].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[8e2d43f7-48fd-4bcf-8128-c49061731ab6].Value" data-valmsg-replace="true"></span>
<p data-sc-field-key="4430F1612AEC4B8DA5BBD81E56A94D67" class="small">O email indicado neste campo receberá a notificação de receção deste pedido de contacto</p><label data-sc-field-key="01DA6E501CAC4EFCA7C08C04FC306149" class="pt-4 bold"
style="display: none;">Email Cliente</label><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_4e397d84-c449-4fc7-a19a-c93cd1ceef8e" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden"
value="4e397d84-c449-4fc7-a19a-c93cd1ceef8e"><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_4e397d84-c449-4fc7-a19a-c93cd1ceef8e__ItemId"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[4e397d84-c449-4fc7-a19a-c93cd1ceef8e].ItemId" type="hidden" value="4e397d84-c449-4fc7-a19a-c93cd1ceef8e"><label
for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_4e397d84-c449-4fc7-a19a-c93cd1ceef8e__Value" class="pt-4 bold" style="display: none;"></label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_4e397d84-c449-4fc7-a19a-c93cd1ceef8e__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[4e397d84-c449-4fc7-a19a-c93cd1ceef8e].Value" class="form-control" type="email"
value="" maxlength="255" placeholder="exemplo@exemplo.pt" data-sc-tracking="True" data-sc-field-name="Email_Cliente" data-sc-field-key="6AB0D9D2B656428187F5AC3C8021672C" data-val-regex="Por favor, introduza um endereço eletrónico válido."
data-val-regex-pattern="^[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,17}$" data-val="true" disabled="" style="display: none;"><input type="hidden"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[4e397d84-c449-4fc7-a19a-c93cd1ceef8e].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[4e397d84-c449-4fc7-a19a-c93cd1ceef8e].Value" data-valmsg-replace="true"></span>
</div>
<div data-sc-field-key="9DF93EBBD6BE4DA385CDD0BE5933260F" class="pt-4">
<h6 data-sc-field-key="F360AAF7D6774321AAD7E2CE9080092A" class="pt-3">Dados do processo</h6><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_e941cd4d-77ca-4f2f-9606-fdff5a0a3a71"
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<div data-sc-field-key="EA2F6F27713142C7837A4241B691366E" class="pt-4">
<h6 data-sc-field-key="A56375FED2E74F8790A382525EC2B296" class="pt-3">Documentos a anexar</h6>
<p data-sc-field-key="1D4CD87209EB4235BFA039CE8CFEBB7F" class="">Faça o download formulário pretendido através dos links que surgem abaixo. Preencha o mesmo e anexe ao pedido, escolhendo a tipificação do documento respetivo. No envio do seu
pedido, os ficheiros a anexo, só podem ter, no total de todos os documentos anexos, 10MB. Caso faça o envio através de um dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens, para que os
ficheiros anexados tenham o tamanho mais reduzido possível. </p>
<div data-sc-field-key="71E8B54BA45F44339449C62F601AA146" class="pt-2" style="display: none;">
<span data-sc-field-key="6671F52FF4A8400CBD68CA2989A4F89A" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/1cd800c1be284ae9b1c00adce7aee310.ashx">Pedido de informação clínica cirúrgico internamento</a></span>
<span data-sc-field-key="9863168A7D234BEA8A1F91D4F8D6075D" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/5b43c49acf0249faa02439f8686d2bf0.ashx">Pedido informação clínica dermatologia</a></span>
<span data-sc-field-key="C427A9661E4744309F5D90CE7060CCF6" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/22a32ab9a6414765a00383435f9325e7.ashx">Pedido informação clínica fisioterapia</a></span>
<span data-sc-field-key="AC9FCE1EA6234422A9A728964E45F45F" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/66d0bcccccf743b38308618b00a1e970.ashx">Pedido informação clínica Meios Complementares de Diagnóstico</a></span>
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<span data-sc-field-key="568F75DAAE404817B60E473FB9303287" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/62fd2da856b747688e995ed6f945b229.ashx">Pedido informação clínica quimioterapia</a></span>
</div>
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<p data-sc-field-key="02D2959F42BD4EDD98DDC375A9F3BC6F" class=""></p>
<span data-sc-field-key="7678DCC4DBC94B7F8232EB9DD40DB4A0" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/1cd800c1be284ae9b1c00adce7aee310.ashx">Pedido de informação clínica cirúrgico internamento</a></span>
<span data-sc-field-key="DE7CB16B80D44997BED0AF64D726260F" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/5b43c49acf0249faa02439f8686d2bf0.ashx">Pedido de informação clínica dermatologia</a></span>
<span data-sc-field-key="8784ABDF850F48D78E4CB201162B9A78" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/22a32ab9a6414765a00383435f9325e7.ashx">Pedido informação clínica fisioterapia</a></span>
<span data-sc-field-key="D0513EDDDB5F42BCB051BE3D9B3411B1" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/66d0bcccccf743b38308618b00a1e970.ashx">Pedido informação clínica Meio Auxiliar de Diagnóstico</a></span>
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<span data-sc-field-key="F77B1479B54947A8AB3973A96B003415" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/62fd2da856b747688e995ed6f945b229.ashx">Pedido informação clínica quimioterapia</a></span>
</div>
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<span data-sc-field-key="48A6994778444F8FA882154EC12F6B2D" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/1a9325cf07f744bc8986b74fe28e1ace.ashx">Pedido de Informação Clínica Cirurgico/Internamento</a></span>
<span data-sc-field-key="E581C1451B45461AB3A5A052FA31741B" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/34c5733f89a54eac96b507db50fdb4f6.ashx">Pedido de Informação Clínica Meio Auxiliar de Diagnóstico</a></span>
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<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/a73928abb9d64bfeb2c83b8ce7d47cb7.ashx">Pedido de Informação Clínica Parto</a></span>
<span data-sc-field-key="B313131B18C449F79F707AAD203A1F32" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/f8ad8e9207f0470baabbad055bc2e844.ashx">Pedido de Informação Clínica Fisioterapia</a></span>
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<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/88af6f318b2c46c69c5658a76e643b09.ashx">Pedido de Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="3502148745CC4BB593A8BE59167B1053" class="form-field--text " style="display: none;">
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</div>
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<span data-sc-field-key="B7EDF7CE32BD492192BBA9DC9C862574" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/b861cc5154094aedaa6170f2ecaad1b4.ashx">Pedido de Informação Clínica Cirurgico Internamento</a></span>
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<br>
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<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/cce2ea2338e54302b2439d421732880c.ashx">Pedido de Informação Clínica Dermatologia</a></span>
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<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/240b43cfc2c64e609b072bafd0f74022.ashx">Pedido de Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="C724192E241F4A73A8F0EA7B8AB303CF" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/86a40728c41145f78bd3eca237135194.ashx">Pedido de Informação Clínica Fisioterapia</a></span>
<span data-sc-field-key="312B03C7AA4D45DF9816FED9FF954F2A" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/caef3f7e74004a3a875a47a16f12e8a2.ashx">Pedido de Informação Clínica Parto</a></span>
</div>
<div data-sc-field-key="AC3781D7436547F7BF40D8E9AD1A96CB" class="pt-2" style="display: none;">
<span data-sc-field-key="9942715ABEEA4F978D2B2A18ED84F96A" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/0efc1f428f5a440c8d03f79be67b052d.ashx">Pedido de Informação Clínica Cirúrgico Internamento</a></span>
<span data-sc-field-key="186964FD4FBA43BAA81131BDED82A2E6" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/3b229856a5a7415e9fbda66c811797c7.ashx">Pedido de Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="53CC29B3F1B74F0BABAFC01640FF65D7" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/b0a24818625f4b3bbecbbd6f80a49716.ashx">Pedido de Informação Clínica Fisioterapia</a></span>
<span data-sc-field-key="18624DB7D2B74D1CB4245773FEC28F3B" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/c1aaba5e9be34087a51aa33997f3d9bd.ashx">Pedido de Informação Clínica Parto</a></span>
</div>
<div data-sc-field-key="0758BC796B574F6EAAFE08F703065300" class="pt-2" style="display: none;">
<span data-sc-field-key="45661841C36041ECA49FBF4F389D3D6C" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/a8b09d2a02254ccca81b9d73ab1902e7.ashx">Pedido de Informação Clínica Cirúrgico Internamento</a></span>
<span data-sc-field-key="3975D445C6884A898DD155793CE73F64" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/b146e88a6979476babd0fc9c358ba32b.ashx">Pedido de Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="D0756E1ADE8F4951ACC1A1602FD5513E" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/0ca59dd69f3a488ea4f9cb8447b51334.ashx">Pedido de Informação Clínica Fisioterapia</a></span>
<span data-sc-field-key="D0DA4F7ECB0C4806AD7DC462EA29486A" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/d3ef8cfe8d744380a3c99a6eb744a359.ashx">Pedido de Informação Clínica Parto</a></span>
</div>
<div data-sc-field-key="D62213A0420D414FAA340F0FD1CE655F" class="pt-2" style="display: none;">
<span data-sc-field-key="C8ED55831F7943AC8F8C8C0672591565" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/0c288009b39940969731b404984f45eb.ashx">Pedido de Informação Clínica Cirúrgico Internamento</a></span>
<span data-sc-field-key="073301B28E4D44EB9E38A1A7DD8384D0" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/0ca32ddcd3dd4296b92d04c2145a5071.ashx">Pedido de Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="EF2AFDC4098C425EA9DA3686A8EDA92D" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/718b080fd4564f50beb59bc3744745a5.ashx">Pedido de Informação Clínica Fisioterapia</a></span>
<span data-sc-field-key="FD4B0789C4BF48FC9C39C53A22F6217F" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/537d62421ae3483ea3d98d2d4791d1db.ashx">Pedido de Informação Clínica Parto</a></span>
</div>
<div data-sc-field-key="A334EBE015684BA791CA5C0EBD60E04A" class="pt-2" style="display: none;">
<span data-sc-field-key="AF889C56C71E4EFBB9B320DC907C6F21" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/a778095be1414ee794594e8b63ac9b49.ashx">Pedido de Informação Clínica Cirúrgico Internamento</a></span>
<span data-sc-field-key="90ED77AFFF124F9D9B23B5B89208F099" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/164d23c562c3461f8ec699343cefc8fc.ashx">Pedido de Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="2600714FCCCD473BA608963A8BE1079E" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/5eac5232f9fc48a6ac0f4cd3ace9de22.ashx">Pedido de Informação Clínica Fisioterapia</a></span>
<span data-sc-field-key="8A3B7AB72E7949A3B69AF10580A30F7D" class="form-field--text blank" style="display: none;">
<a class="form-field-link" target="" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/57c841fd3e4448e9acc2ea6f8f4397d6.ashx">Pedido de Informação Clínica Parto</a></span>
</div>
<div data-sc-field-key="96877276ECC24F56A1713D67C3E5409B" class="pt-2" style="display: none;">
<span data-sc-field-key="C659ABFB2B474B1B947AE012BC82F2BF" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/d1026e347b7140ae8463b3a4bf2a6c76.ashx">Pedido de Informação Clínica Cirúrgico Internamento</a></span>
<span data-sc-field-key="A3C3539613474871B3E32BE4571D3277" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/62797b61db894e3e9003a6a8ab99d55b.ashx">Pedido de Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="1CD162A22FFE42C68A3B5E788D730E9D" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/a3fa1e51bd62451b94b1072c025e8efc.ashx">Pedido de Informação Clínica Fisioterapia</a></span>
<span data-sc-field-key="95C7234FD2B94DD68255D76BEE158743" class="form-field--text " style="display: none;">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/caabe7d80b784acb80db5fca1b1daf64.ashx">Pedido de Informação Clínica Parto</a></span>
</div>
<div data-sc-field-key="8CA0E77FEF77417DAD61A27D32839EC1" class="pt-2" style="display: none;">
<span data-sc-field-key="3D3CE0BD70F9414D85F9005291AA54D6" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/b01a3cc0775345ef9049dc7664e0589b.ashx">Pedido de Informação Clínica Cirúrgico Internamento</a></span>
<span data-sc-field-key="73B6FBAB7B834B18A38CF6D559B523FA" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/4fda327135664b06bdc44cffc82dbd1e.ashx">Pedido Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="C42D5A93958F4EE9A03311045E95DE3E" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/d116854461644b5695e92251457fb27a.ashx">Pedido Informação Fisioterapia</a></span>
<span data-sc-field-key="8AB493F4E5DA47D79921D0B4BEBA3AD8" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/429eed5fb7ed46aab5a512a7694161a3.ashx">Pedido Informação Clínica MCD</a></span>
<span data-sc-field-key="E87771765E0E41BBB911BA18B2189B38" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/1f710c1617d9413e9608a1ce6fedead5.ashx">Pedido Informação Clínica Parto</a></span>
<span data-sc-field-key="2A043F0658424010820D1AB4C1905F84" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/87a07d0167284dbeac243af28c2092fe.ashx">Pedido Informação Clínica Quimioterapia</a></span>
</div>
<div data-sc-field-key="4FA6B3A3A00948DA9CF6389A84902461" class="pt-2" style="display: none;">
<span data-sc-field-key="A7A9A4172A68430A9A0FF0BA77BD679E" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/29f191eeb37a479c82307402a54478b5.ashx">Pedido de Informação Clínico Cirúrgico Internamento</a></span>
<span data-sc-field-key="3C4676FDDE5E4E348F263C33C839F418" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/3c44b727e7694c089fb4bab4e8111be1.ashx">Pedido Informação Clínica Dermatologia</a></span>
<span data-sc-field-key="3E663C795E0345CDB32F2ADEFA4160C7" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/00280084be6a4fa0b67398888344448f.ashx">Pedido Informação Clínica Fisioterapia</a></span>
<span data-sc-field-key="B0617586D02E4458BFFDBF4A8B1EF1A7" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/b12c01932fe04f27a8ba4f3af31228b0.ashx">Pedido Informação Clínica MCD</a></span>
<span data-sc-field-key="80FEF43D6BCE486E820250C5DC2BC6E9" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/3ec1142b77ca4c0eae4624a6210c23c0.ashx">Pedido Informação Clínica Parto</a></span>
<span data-sc-field-key="CD5B3144FC8F447D9823088ABAAD4D8E" class="form-field--text ">
<a class="form-field-link" target="blank" href="https://eaacprsg016-pt-advancecare-261660-cd.azurewebsites.net/-/media/232db14d61b34c8aa3d1456f52d92cc0.ashx">Pedido Informação Clínica Parto</a></span>
</div>
</div>
<div data-sc-field-key="D23187EBB2024F4DB7D89F2288CCB0DB" class="">
<div data-sc-field-key="4346D1EE9CFB4D66B7818564794D8A6C" class="row">
<div data-sc-field-key="1C11D41EAF0D42999B67247C72777AA1" class="col-12 file-form">
<h6 data-sc-field-key="E08D028EDEA04980A789686604D75762" class="bold pt-3 pb-3">Descrição detalhada da situação que originou a lesão/Acidente</h6><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_772767bf-9847-4cc7-bc54-4ab7f6107eea" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="772767bf-9847-4cc7-bc54-4ab7f6107eea"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_772767bf-9847-4cc7-bc54-4ab7f6107eea__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[772767bf-9847-4cc7-bc54-4ab7f6107eea].ItemId" type="hidden"
value="772767bf-9847-4cc7-bc54-4ab7f6107eea">
<div class="form-file-upload file-drag">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[772767bf-9847-4cc7-bc54-4ab7f6107eea].Files" data-valmsg-replace="true"></span>
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_772767bf-9847-4cc7-bc54-4ab7f6107eea__Files" class="pt-4 bold">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_772767bf-9847-4cc7-bc54-4ab7f6107eea__Files" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[772767bf-9847-4cc7-bc54-4ab7f6107eea].Files" class="file-drag" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="formularioDescricaoAcidente" data-sc-field-key="0A37BB21E23D42EAB5A89DADAF240A2D"><button class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="837A5F3DE05B4B6ABE939500E77AD7A7" class="small">Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas
definições, as permissões de acesso à câmara e galeria de imagens.</p>
</div>
<div data-sc-field-key="E8E9B3CC3DA84640972F557039CCF300" class="col-12 file-form">
<h6 data-sc-field-key="8293AA66842B436F987178BE3A21B917" class="bold pt-3 pb-3">Pedido de informação clínica</h6><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_81c5168b-b64f-4052-8476-e9fc8b3ddc08"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="81c5168b-b64f-4052-8476-e9fc8b3ddc08"><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_81c5168b-b64f-4052-8476-e9fc8b3ddc08__ItemId"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[81c5168b-b64f-4052-8476-e9fc8b3ddc08].ItemId" type="hidden" value="81c5168b-b64f-4052-8476-e9fc8b3ddc08">
<div class="form-file-upload file-drag">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[81c5168b-b64f-4052-8476-e9fc8b3ddc08].Files" data-valmsg-replace="true"></span>
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_81c5168b-b64f-4052-8476-e9fc8b3ddc08__Files" class="pt-4 bold">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_81c5168b-b64f-4052-8476-e9fc8b3ddc08__Files" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[81c5168b-b64f-4052-8476-e9fc8b3ddc08].Files" class="file-drag" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="PedidoDeInformacaoClinica" data-sc-field-key="979AD65638924CA2806918916E6BEA5B"><button class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="6DECE4B5D0204E008070B4647B72BA02" class="small">Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas
definições, as permissões de acesso à câmara e galeria de imagens.</p>
</div>
<div data-sc-field-key="44B549993D4B4E8CAE5CB57D7637ED5B" class="col-12 file-form">
<h6 data-sc-field-key="E3B326B8B1E44058B0AE96A9BCABC11F" class="bold pt-3 pb-3">Relatórios Médicos</h6><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_a388a98d-a74d-4e2d-a73b-d1c422edcb5a"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="a388a98d-a74d-4e2d-a73b-d1c422edcb5a"><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_a388a98d-a74d-4e2d-a73b-d1c422edcb5a__ItemId"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[a388a98d-a74d-4e2d-a73b-d1c422edcb5a].ItemId" type="hidden" value="a388a98d-a74d-4e2d-a73b-d1c422edcb5a">
<div class="form-file-upload file-drag">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[a388a98d-a74d-4e2d-a73b-d1c422edcb5a].Files" data-valmsg-replace="true"></span>
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_a388a98d-a74d-4e2d-a73b-d1c422edcb5a__Files" class="pt-4 bold">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_a388a98d-a74d-4e2d-a73b-d1c422edcb5a__Files" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[a388a98d-a74d-4e2d-a73b-d1c422edcb5a].Files" class="file-drag" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="relatoriosMedicos" data-sc-field-key="70C12B117DEF4F2CBDC9B5265514C606"><button class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="5599BA27195848209A8EA5847F96A67E" class="small">Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas
definições, as permissões de acesso à câmara e galeria de imagens.</p>
</div>
<div data-sc-field-key="B8528B1B78654382A8DC5008AD5D11CB" class="col-12 file-form">
<h6 data-sc-field-key="1E2EEA0D7B24433497BBA0FC5A141E1C" class="bold pt-3 pb-3">Exames complementares de diagnóstico</h6><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_17aa298c-040a-408b-8f5c-055cf0f3e36e"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="17aa298c-040a-408b-8f5c-055cf0f3e36e"><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_17aa298c-040a-408b-8f5c-055cf0f3e36e__ItemId"
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<div class="form-file-upload file-drag">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[17aa298c-040a-408b-8f5c-055cf0f3e36e].Files" data-valmsg-replace="true"></span>
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_17aa298c-040a-408b-8f5c-055cf0f3e36e__Files" class="pt-4 bold">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_17aa298c-040a-408b-8f5c-055cf0f3e36e__Files" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[17aa298c-040a-408b-8f5c-055cf0f3e36e].Files" class="file-drag" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="examesComplementaresDeDiagnostico" data-sc-field-key="DB773032FA294B80846BBB5CD5061425"><button class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="9E40C90B74A6420DB839711488380B26" class="small">Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas
definições, as permissões de acesso à câmara e galeria de imagens.</p>
</div>
<div data-sc-field-key="02F2F18DA9214DC791E632E69A7E90B1" class="col-12 file-form">
<h6 data-sc-field-key="DA5369C603824C889B8093E50E038630" class="bold pt-3 pb-3">Pré-fatura</h6><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_c002bc72-dbc5-4cc9-9cff-ff7b21afca87"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="c002bc72-dbc5-4cc9-9cff-ff7b21afca87"><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_c002bc72-dbc5-4cc9-9cff-ff7b21afca87__ItemId"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[c002bc72-dbc5-4cc9-9cff-ff7b21afca87].ItemId" type="hidden" value="c002bc72-dbc5-4cc9-9cff-ff7b21afca87">
<div class="form-file-upload file-drag">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[c002bc72-dbc5-4cc9-9cff-ff7b21afca87].Files" data-valmsg-replace="true"></span>
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_c002bc72-dbc5-4cc9-9cff-ff7b21afca87__Files" class="pt-4 bold">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_c002bc72-dbc5-4cc9-9cff-ff7b21afca87__Files" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[c002bc72-dbc5-4cc9-9cff-ff7b21afca87].Files" class="file-drag" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="preFatura" data-sc-field-key="4DA5D52DDAD44720B3795CD854D67BFD"><button class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="13CA9862C6A44DCC853840B6D6E5949B" class="small">Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas
definições, as permissões de acesso à câmara e galeria de imagens.</p>
</div>
<div data-sc-field-key="AE49FD7C139D44499268847A51467C37" class="col-12 file-form">
<h6 data-sc-field-key="66BB386DE71C40599489745923EDD082" class="bold pt-3 pb-3">Nota de alta</h6><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_5268208c-1ed8-4a28-8902-ff396235d000"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="5268208c-1ed8-4a28-8902-ff396235d000"><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_5268208c-1ed8-4a28-8902-ff396235d000__ItemId"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[5268208c-1ed8-4a28-8902-ff396235d000].ItemId" type="hidden" value="5268208c-1ed8-4a28-8902-ff396235d000">
<div class="form-file-upload file-drag">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[5268208c-1ed8-4a28-8902-ff396235d000].Files" data-valmsg-replace="true"></span>
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_5268208c-1ed8-4a28-8902-ff396235d000__Files" class="pt-4 bold">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_5268208c-1ed8-4a28-8902-ff396235d000__Files" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[5268208c-1ed8-4a28-8902-ff396235d000].Files" class="file-drag" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="notaDeAlta" data-sc-field-key="3D53E8295A00435884C737CE8FD71FC4"><button class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="4462BC09D2E1486189F5F45C547FD758" class="small">Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas
definições, as permissões de acesso à câmara e galeria de imagens.</p>
</div>
<div data-sc-field-key="36F7E489CE3B47B29D6CEDDCF0A5D71A" class="col-12">
<h6 data-sc-field-key="A98D206460014390BB7B261964C0F01B" class="bold pt-3 pb-3">Outros</h6><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_edb9b238-ff1b-4758-95ba-d7f8b69af2df"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="edb9b238-ff1b-4758-95ba-d7f8b69af2df"><input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_edb9b238-ff1b-4758-95ba-d7f8b69af2df__ItemId"
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<div class="form-file-upload file-drag">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[edb9b238-ff1b-4758-95ba-d7f8b69af2df].Files" data-valmsg-replace="true"></span>
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_edb9b238-ff1b-4758-95ba-d7f8b69af2df__Files" class="pt-4 bold">Arraste para este espaço os ficheiros ou</label>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_edb9b238-ff1b-4758-95ba-d7f8b69af2df__Files" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[edb9b238-ff1b-4758-95ba-d7f8b69af2df].Files" class="file-drag" type="file"
multiple="" data-sc-tracking="True" data-sc-field-name="Outros" data-sc-field-key="71F8D87E358B4CD795286543D93ADF55"><button class="btn btn-primary--outline adv-upload">Selecionar Ficheiro</button>
<span class="adv-upload label" style="display:block"></span>
</div>
<p data-sc-field-key="5FEDCA42FE524192978338D5290D6E29" class="small">Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas
definições, as permissões de acesso à câmara e galeria de imagens.</p>
</div>
</div>
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_4e9d2651-b917-430e-bbf8-aa534823855a" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="4e9d2651-b917-430e-bbf8-aa534823855a"><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_4e9d2651-b917-430e-bbf8-aa534823855a__ItemId" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[4e9d2651-b917-430e-bbf8-aa534823855a].ItemId" type="hidden"
value="4e9d2651-b917-430e-bbf8-aa534823855a"><label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_4e9d2651-b917-430e-bbf8-aa534823855a__Value" class="pt-4 bold">Mensagem *</label>
<textarea id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_4e9d2651-b917-430e-bbf8-aa534823855a__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[4e9d2651-b917-430e-bbf8-aa534823855a].Value" class="form-control" rows="6"
maxlength="1000" placeholder="Descreva de forma detalhada o motivo do seu contacto" data-sc-tracking="True" data-sc-field-name="Multiple-Line Text" data-sc-field-key="DFE90E99C108483A8D83FBFEE9C1F8B0" data-val-required=" "
data-val="true"></textarea><input type="hidden" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[4e9d2651-b917-430e-bbf8-aa534823855a].Required" value="false" data-sc-conditions-required="">
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[4e9d2651-b917-430e-bbf8-aa534823855a].Value" data-valmsg-replace="true"></span>
<p data-sc-field-key="F55AFC237ABB4E35994996C487861FEC" class="pt-4">(*) campos de preenchimento obrigatório, sob pena de não ser possível finalizar a submissão do pedido</p><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_f49b7399-2900-4b63-8a76-572c364f9f1c" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="f49b7399-2900-4b63-8a76-572c364f9f1c"><input
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value="f49b7399-2900-4b63-8a76-572c364f9f1c">
<div class="">
<input type="checkbox" id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_f49b7399-2900-4b63-8a76-572c364f9f1c__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[f49b7399-2900-4b63-8a76-572c364f9f1c].Value" class="" value="true"
data-sc-tracking="True" data-sc-field-name="termsandconditions" data-sc-field-key="29B2F3725D0C4706B696870CD6C657FF" data-val-ischecked=" " data-val-required="The Value field is required." data-val="true">
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_f49b7399-2900-4b63-8a76-572c364f9f1c__Value"></label>
<input type="hidden" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[f49b7399-2900-4b63-8a76-572c364f9f1c].Value" value="false"><input type="hidden"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[f49b7399-2900-4b63-8a76-572c364f9f1c].Required" value="false" data-sc-conditions-required="">
</div>
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[f49b7399-2900-4b63-8a76-572c364f9f1c].Value" data-valmsg-replace="true"></span>
<span data-sc-field-key="8D0C891E314243CDBA832DC31E239328" class="form-field--text "> Declaro que li e aceito os
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/termos-condicoes-formularios">termos e condições</a> apresentados *</span><input
id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_Index_084369b9-89ac-401c-aaca-ca88b629a1e9" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields.Index" type="hidden" value="084369b9-89ac-401c-aaca-ca88b629a1e9"><input
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value="084369b9-89ac-401c-aaca-ca88b629a1e9">
<div class="">
<input type="checkbox" id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_084369b9-89ac-401c-aaca-ca88b629a1e9__Value" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[084369b9-89ac-401c-aaca-ca88b629a1e9].Value" class="" value="true"
data-sc-tracking="True" data-sc-field-name="protectiondata" data-sc-field-key="351E80EBA7C347A68A1097DDFFD95E56" data-val-ischecked=" " data-val-required="The Value field is required." data-val="true">
<label for="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_Fields_084369b9-89ac-401c-aaca-ca88b629a1e9__Value"></label>
<input type="hidden" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[084369b9-89ac-401c-aaca-ca88b629a1e9].Value" value="false"><input type="hidden"
name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[084369b9-89ac-401c-aaca-ca88b629a1e9].Required" value="false" data-sc-conditions-required="">
</div>
<span class="field-validation-valid" data-valmsg-for="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.Fields[084369b9-89ac-401c-aaca-ca88b629a1e9].Value" data-valmsg-replace="true"></span>
<span data-sc-field-key="2786FA440B7147B6A18D790CD94635F6" class="form-field--text "> Declaro que li e aceito a
<a class="form-field-link" target="blank" href="https://www.advancecare.pt/institucional/informacoes-legais/politicas/protecao-de-dados-pessoais">política de tratamento de dados pessoais</a> AdvanceCare *</span>
</div>
</div>
<div data-sc-field-key="0DC01C29273348B4BB6D60DFA21596A0" class="modal">
<div data-sc-field-key="5F2BD5A0A6364AB193C4651B12BFE95D" class="modal-dialog">
<div data-sc-field-key="9D77362F888E48ABAF31895499AF99F6" class="modal-content p-4">
<div data-sc-field-key="D9E8D115C56347A1938382096E30E49D" class="modal-header-block pt-5 ">
<div data-sc-field-key="AB17B0F4F45F431FACBC7B0D9D9077C6" class="modal-title">
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
<h3 data-sc-field-key="84186AB948FD4CA184BE75EBF56A144E" class="text-center">Formulário enviado com sucesso!</h3><br>
</div>
</div>
</div>
</div>
</div>
<div data-sc-field-key="323A01373F9D4CACAE163D345955E80E" class="pt-5 text-center">
<input value="Enviar" type="submit" class="btn btn-primary modal-form send" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.29e98e5d-df8d-42b9-a9af-f958ed89f1d2" data-sc-field-key="7F1A4246631D4410826593B94CDC242F" disabled="">
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_NavigationButtons" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.NavigationButtons" type="hidden" value="29e98e5d-df8d-42b9-a9af-f958ed89f1d2">
<input id="fxb_3a088a2b-6a49-454e-b38c-fac7f42a4d6e_29e98e5d-df8d-42b9-a9af-f958ed89f1d2" name="fxb.3a088a2b-6a49-454e-b38c-fac7f42a4d6e.29e98e5d-df8d-42b9-a9af-f958ed89f1d2" type="hidden" value="0">
</div>
</div>
<input type="hidden" data-name="pedido-pre-autorizacao" data-friend-name="Pedido de pré-autorização" data-sc-fxb-condition="" value="{
"fieldConditions": [
{
"matchType": "any",
"conditions": [
{
"fieldId": "FFF4E18EEE304059879DC217A1A21649",
"operator": "is equal to",
"value": "Segurado / Utente / Beneficiário / Representante"
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{
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"actionType": "hideDisable",
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{
"matchType": "any",
"conditions": [
{
"fieldId": "FFF4E18EEE304059879DC217A1A21649",
"operator": "is not equal to",
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{
"matchType": "all",
"conditions": [
{
"fieldId": "FFF4E18EEE304059879DC217A1A21649",
"operator": "is equal to",
"value": "Prestador Convencionado "
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"actions": [
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{
"matchType": "any",
"conditions": [
{
"fieldId": "FFF4E18EEE304059879DC217A1A21649",
"operator": "is not equal to",
"value": "Prestador Convencionado "
}
],
"actions": [
{
"fieldId": "EE4A9F3EBA8B438C82E09ACDB898C4BC",
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{
"matchType": "any",
"conditions": [
{
"fieldId": "EE4A9F3EBA8B438C82E09ACDB898C4BC",
"operator": "is equal to",
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},
{
"fieldId": "EE4A9F3EBA8B438C82E09ACDB898C4BC",
"operator": "is equal to",
"value": "Sim, contudo encontra-se indisponível"
},
{
"fieldId": "FFF4E18EEE304059879DC217A1A21649",
"operator": "is equal to",
"value": "Segurado / Utente / Beneficiário / Representante"
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{
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{
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"operator": "is equal to",
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<div data-sc-field-key="2E4F9D46A1B946A98B2859742A0387AA" class="">
<div data-sc-field-key="0767A05995404DAAB864505BDD07BF09" class="row pb-3">
<div data-sc-field-key="82C38E76327342A8BB94F856FBD42E64" class="col-1">
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<br><br>
<div data-sc-field-key="F03FCDE0E923432F9801A031BFD42AE2" class="text-center pb-4 col-10 pt-4">
<h4 data-sc-field-key="51304AB15D834DCA9DFF31D262153E92" class="">Receba os nossos conteúdos de saúde e bem-estar:</h4>
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<br>
<div data-sc-field-key="A6DB9302498B43E58055553A8DB9C561" class="col-12">
<p data-sc-field-key="1D28D08666C84BA6AD9B9D51AF40993C" class="bold">Escolha os temas que mais lhe interessam:</p>
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<label for="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_4bcbfc97-b672-46e0-94c8-217a08d7d1bd__Value">Bem-estar</label>
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id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_Index_858a6bf8-46ba-4861-b04d-cff4c7bdbb3f" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields.Index" type="hidden" value="858a6bf8-46ba-4861-b04d-cff4c7bdbb3f"><input
id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_858a6bf8-46ba-4861-b04d-cff4c7bdbb3f__ItemId" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[858a6bf8-46ba-4861-b04d-cff4c7bdbb3f].ItemId" type="hidden"
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<div class="">
<input type="checkbox" id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_858a6bf8-46ba-4861-b04d-cff4c7bdbb3f__Value" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[858a6bf8-46ba-4861-b04d-cff4c7bdbb3f].Value" class="checkbox"
value="true" data-sc-tracking="True" data-sc-field-name="estetica" data-sc-field-key="B84349F918D9402FA177DF543A0624A0" data-val-required="The Value field is required." data-val="true">
<label for="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_858a6bf8-46ba-4861-b04d-cff4c7bdbb3f__Value">Estética</label>
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<div class="">
<input type="checkbox" id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_19425d52-babc-48d4-a44d-e226790a08fc__Value" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[19425d52-babc-48d4-a44d-e226790a08fc].Value" class="checkbox"
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<div data-sc-field-key="455129D775EE479291AE82B386BBB07E" class="col-md-6 col-sm-12">
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<div class="">
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<label for="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_219b258d-055d-4f96-b074-14d4672100aa__Value">Doenças e tramentos</label>
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<span class="field-validation-valid" data-valmsg-for="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[219b258d-055d-4f96-b074-14d4672100aa].Value" data-valmsg-replace="true"></span><input
id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_Index_f972127d-5da5-4e40-b0ff-48f455a1833c" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields.Index" type="hidden" value="f972127d-5da5-4e40-b0ff-48f455a1833c"><input
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<div class="">
<input type="checkbox" id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_f972127d-5da5-4e40-b0ff-48f455a1833c__Value" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[f972127d-5da5-4e40-b0ff-48f455a1833c].Value" class="checkbox"
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<input type="hidden" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[f972127d-5da5-4e40-b0ff-48f455a1833c].Value" value="false">
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<span class="field-validation-valid" data-valmsg-for="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[f972127d-5da5-4e40-b0ff-48f455a1833c].Value" data-valmsg-replace="true"></span><input
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<div class="">
<input type="checkbox" id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_22eac36d-cf52-4b43-8d33-c1b41b9caf13__Value" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[22eac36d-cf52-4b43-8d33-c1b41b9caf13].Value" class="checkbox"
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<label for="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_22eac36d-cf52-4b43-8d33-c1b41b9caf13__Value">Prevenção</label>
<input type="hidden" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[22eac36d-cf52-4b43-8d33-c1b41b9caf13].Value" value="false">
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<span class="field-validation-valid" data-valmsg-for="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[22eac36d-cf52-4b43-8d33-c1b41b9caf13].Value" data-valmsg-replace="true"></span>
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</div>
<input id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_Index_0232fe5b-2751-4323-acb3-0ca80c295f9a" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields.Index" type="hidden" value="0232fe5b-2751-4323-acb3-0ca80c295f9a"><input
id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_0232fe5b-2751-4323-acb3-0ca80c295f9a__ItemId" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[0232fe5b-2751-4323-acb3-0ca80c295f9a].ItemId" type="hidden"
value="0232fe5b-2751-4323-acb3-0ca80c295f9a"><label for="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_0232fe5b-2751-4323-acb3-0ca80c295f9a__Value" class="pt-4 bold">Preencha o seu email:</label>
<input id="fxb_bd42963c-aca9-4d76-bbd4-514ce3197576_Fields_0232fe5b-2751-4323-acb3-0ca80c295f9a__Value" name="fxb.bd42963c-aca9-4d76-bbd4-514ce3197576.Fields[0232fe5b-2751-4323-acb3-0ca80c295f9a].Value" class="form-control" type="email" value=""
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<p data-sc-field-key="7AE631C010034AD0B8ED02A31BAA0AB1" class="small pb-3">(*) Campos de preenchimento obrigatório</p>
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<span data-sc-field-key="FA59F70558EB410EB71A12FCCB282400" class="form-field--text "> Declaro que li e aceito os
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<span data-sc-field-key="E0629A79AC094CC5A242F4015D4258A7" class="form-field--text "> Declaro que li e aceito a
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<span data-sc-field-key="E27F41AF735845C5BE1B076DC17436BA" class="form-field--text "> Autorizo o tratamento dos meus dados pela AdvanceCare para efeitos de comunicações de produtos e serviços próprios e outras comunicações comerciais, através
deste e-mail.</span>
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AdvanceCare Cancelar conversa com o assistente Powered by Visor.ai A tentar estabelecer ligação * Recomeçar * Powered by Visor.ai Para continuar, clique num botão acima Começar Fale connosco Para si Para empresas Institucional * Seguros de Saúde * Rede Médica * Biblioteca de Saúde * Care & Go myAdvanceCare * Seguros de Saúde * Rede Médica * Biblioteca de Saúde * Care & Go * Site AdvanceCare Ajuda FALE CONNOSCO * Linkedin * Mail * whatsapp OLÁ. COMO PODEMOS AJUDAR? AINDA NÃO TEM A APP MYADVANCECARE? Aceda ao seu seguro ou plano de saúde de forma simples e rápida, e obtenha todas as informações que precisa. Faça o download agora ou aceda na versão web. JÁ TEM A APP MYADVANCECARE? No myAdvanceCare queremos cuidar da sua saúde e estamos à distância de um computador ou telemóvel. DÚVIDAS QUE PODE ESCLARECER ATRAVÉS DO MYADVANCECARE Reembolsos Condições do plano ou seguro de saúde Estimativa de custo de um ato médico Médico Online Pré-autorizações Dados de perfil ou seguro Quer falar com o assistente virtual? Esclareça as suas dúvidas de forma rápida e prática. Entre em contacto connosco através do Whatsapp ou do assistente virtual AdvanceCare disponível no canto inferior direito. OUTROS ASSUNTOS Seguro ou plano de saúdeLoja onlineSugestõesPedido de pré-autorização Seguro ou plano de saúde Seguro ou plano de saúde Loja online Sugestões Pedido de pré-autorização Na utilização deste formulário o utilizador deve tomar conhecimento das seguintes disposições uma vez que é solicitado que forneça previamente dados pessoais. A AdvanceCare S.A é a responsável pelo tratamento dos dados recolhidos neste formulário. Os contactos do responsável e do encarregado da proteção de dados estão disponíveis aqui. Caso o utilizador efetue o seu pedido no âmbito do seu seguro ou plano de benefícios de saúde, a AdvanceCare atua como subcontratante e o fundamento jurídico para o tratamento é a execução enquanto subcontratante das diligências para resposta ao contrato com a seguradora/entidade na gestão de seguros/planos de saúde. Para mais detalhe consulte aqui. O titular dos dados poderá, em qualquer momento, exercer os direitos, veja mais detalhe aqui POR FAVOR, PREENCHA OS SEGUINTES DADOS: Assunto: Reclamação Reclamação Para outros assuntos não relacionados com o tema selecionado, utilize a nossa plataforma myAdvanceCare ou contacte-nos pelos canais alternativos disponíveis no verso do seu cartão. Pedidos de reembolso por esta via não são aceites. Com o objetivo de melhorar a qualidade dos serviços prestados e com o intuito de promover a melhoria contínua dos nossos serviços, a AdvanceCare, entidade certificada pelo referencial da Qualidade NP EN ISO 9001, disponibiliza através deste portal um formulário de reclamações. Conheça a nossa política de reclamações aqui. DADOS DO LESADO Subsistema ou Seguradora * Açoreana Asisa BNP Paribas Cardif Cimentaçor Cimpor Industria Cruz Vermelha Portuguesa Europ Assistance Generali Mudum Seguros Intercement LOGO Lusitania MGEN - Mutuelle Générale de L Education National N Seguros Popular Seguros Real Vida Seguros SAMS SBC SAMS Mais Sindicato Santander Totta Seguros Tranquilidade UNA Seguros União das Misericórdias Portuguesas Vitorino Seguros Açoreana Asisa BNP Paribas Cardif Cimentaçor Cimpor Industria Cruz Vermelha Portuguesa Europ Assistance Generali Mudum Seguros Intercement LOGO Lusitania MGEN - Mutuelle Générale de L Education National N Seguros Popular Seguros Real Vida Seguros SAMS SBC SAMS Mais Sindicato Santander Totta Seguros Tranquilidade UNA Seguros União das Misericórdias Portuguesas Vitorino Seguros Nº do cartão do seguro de saúde / plano de benefícios: Número que consta na frente do cartão do seu seguro de saúde / plano de benefícios NIF * Email * Nº de bilhete de identidade / Cartão de cidadão * Selecione o tipo de documento pretendido * 2ª via Termo de responsabilidade Declaração de comparticipação 2ª via Termo de responsabilidade Declaração de comparticipação Data da despesa/recibo * Valor da despesas * Para apresentar um pedido de esclarecimento, utilize por favor o seguinte link: www.mgen.pt/ajuda. Em alternativa poderá enviar um email para saude@mgen.pt Para apresentar uma reclamação, utilize por favor o seguinte link: www.mgen.pt/reclamacao. Em alternativa poderá enviar um email para reclamacoes@mgen.pt DADOS DO RECLAMANTE Relação com o lesado * Lesado Corretor Recursos humanos – Empresas Advogado Representante legal Outro Lesado Corretor Recursos humanos – Empresas Advogado Representante legal Outro Nome do Corretor * Email do Corretor * Telefone do Corretor * Mensagem * CASO PRETENDA PODERÁ ADICIONAR AQUI DOCUMENTOS ÚTEIS À SUA EXPOSIÇÃO Arraste para este espaço os ficheiros ou Selecionar Ficheiro Os ficheiros a carregar devem ter até 10MB, tendo em atenção o seu formato e qualidade ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens. (*) campos de preenchimento obrigatório, sob pena de não ser possível finalizar a submissão do pedido Declaro que li e aceito os termos e condições apresentados * Declaro que li e aceito a política de tratamento de dados pessoais AdvanceCare * × FORMULÁRIO ENVIADO COM SUCESSO! Se pretende apresentar uma reclamação no âmbito da aquisição de produtos do portal AdvanceCare, por favor preencha os campos abaixo apresentados. Na utilização deste formulário o utilizador deve tomar conhecimento das seguintes disposições uma vez que é solicitado que forneça previamente dados pessoais. A AdvanceCare S.A é a responsável pelo tratamento dos dados recolhidos neste formulário. Os contactos do responsável e do encarregado da proteção de dados estão disponíveis aqui. Os dados recolhidos destinam-se à análise do pedido e atualização de dados. O fundamento jurídico para o tratamento é a necessidade de realização de diligências contratuais solicitadas. Para mais detalhe consulte aqui. O titular dos dados poderá, em qualquer momento, exercer os direitos, veja mais detalhe aqui. POR FAVOR, PREENCHA OS SEGUINTES DADOS: Assunto * Reclamações Reclamações Para outros assuntos não relacionados com o tema selecionado, utilize a nossa plataforma myAdvanceCare ou contacte-nos pelos canais alternativos disponíveis no verso do seu cartão. Pedidos de reembolso por esta via não são aceites. Os cancelamentos podem ser feitos no prazo de 14 dias a contar da data de aquisição ou em situação previstas e devidamente descritas em determinados produtos disponíveis em “loja online”. O envio do presente formulário não invalida o contacto prévio para o número 707 100 005 ou 210 192 816, onde deverá escolher a opção “cancelamento”. Para esclarecimento sobre cancelamentos resultantes de livre resolução. Após correta anulação por parte da AdvanceCare, serão processados a nota de crédito e de reembolso da totalidade ou parte do valor do voucher, de acordo com a situação em causa. Numa perspetiva de melhoria contínua da qualidade dos nossos serviços e da oferta disponibilizada, a AdvanceCare, entidade certificada pelo referencial da Qualidade NP EN ISO 9001, disponibiliza através deste portal um formulário de reclamações. Se pretende apresentar uma reclamação no âmbito da aquisição de produtos do portal AdvanceCare, por favor preencha os campos abaixo apresentados. Conheça a nossa política de reclamações à qual poderá aceder, clicando aqui.Nome * E-mail * Telefone * NIF * Seguradora ou subsistema: Açoreana Asisa BNP Paribas Cardif Cimentaçor Cimpor Industria Cruz Vermelha Portuguesa Europ Assistance Generali Mudum Seguros Intercement LOGO Lusitania MGEN - Mutuelle Générale de L Education National N Seguros Popular Seguros Real Vida Seguros SAMS SBC SAMS Mais Sindicato Santander Totta Seguros Tranquilidade UNA Seguros União das Misericórdias Portuguesas Vitorino Seguros Açoreana Asisa BNP Paribas Cardif Cimentaçor Cimpor Industria Cruz Vermelha Portuguesa Europ Assistance Generali Mudum Seguros Intercement LOGO Lusitania MGEN - Mutuelle Générale de L Education National N Seguros Popular Seguros Real Vida Seguros SAMS SBC SAMS Mais Sindicato Santander Totta Seguros Tranquilidade UNA Seguros União das Misericórdias Portuguesas Vitorino Seguros Número do cartão do seguro de saúde/plano de benefícios: Número que consta na frente do cartão do seu seguro de saúde/plano de benefícios. Nº voucher * Nº voucher Mensagem * CASO PRETENDA PODERÁ ADICIONAR AQUI DOCUMENTOS ÚTEIS À SUA EXPOSIÇÃO Arraste para este espaço os ficheiros ou Selecionar Ficheiro Os ficheiros a carregar devem ter até 10MB, tendo em atenção o seu formato e qualidade ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmera e galeria de imagens. (*) campos de preenchimento obrigatório, sob pena de não ser possível finalizar a submissão do pedido Declaro que li e aceito os termos e condições apresentados * Declaro que li e aceito a política de tratamento de dados pessoais AdvanceCare * × FORMULÁRIO ENVIADO COM SUCESSO! Para outros assuntos não relacionados com o tema selecionado, utilize a nossa plataforma myAdvanceCare ou contacte-nos pelos canais alternativos disponíveis no verso do seu cartão. Pedidos de reembolso por esta via não são aceites. Na utilização deste formulário o utilizador deve tomar conhecimento das seguintes disposições uma vez que é solicitado que forneça previamente dados pessoais. A AdvanceCare S.A é a responsável pelo tratamento dos dados recolhidos neste formulário. Os contactos do responsável e do encarregado da proteção de dados estão disponíveis . Os dados recolhidos destinam-se à análise do pedido e atualização de dados. O fundamento jurídico para o tratamento é a necessidade de realização de diligências contratuais solicitadas. Para mais detalhe consulte aqui. O titular dos dados poderá, em qualquer momento, exercer os direitos, veja mais detalhe aqui. POR FAVOR PREENCHA OS SEGUINTES DADOS: Nome * E-mail * NIF Seguradora ou subsistema: Açoreana Asisa BNP Paribas Cardif Cimentacor Cimpor Industria Cruz Vermelha Portuguesa Europ Assistance Generali GNB - Companhia de Seguros Intercement LOGO Lusitania MGEN N Seguros Popular Seguros Real Vida Seguros SAMS SBC SAMS SBSI Santander Totta Seguros Tranquilidade UNA Uniao das Misericordias Portuguesas Vitorino Seguros Açoreana Asisa BNP Paribas Cardif Cimentacor Cimpor Industria Cruz Vermelha Portuguesa Europ Assistance Generali GNB - Companhia de Seguros Intercement LOGO Lusitania MGEN N Seguros Popular Seguros Real Vida Seguros SAMS SBC SAMS SBSI Santander Totta Seguros Tranquilidade UNA Uniao das Misericordias Portuguesas Vitorino Seguros Nº do cartao do seguro de saúde / plano de benefícios: Número que consta na frente do cartão do seu seguro de saúde/plano de benefícios. Mensagem * CASO PRETENDA PODERÁ ADICIONAR AQUI DOCUMENTOS ÚTEIS À SUA EXPOSIÇÃO: Arraste para este espaço os ficheiros ou Selecionar Ficheiro Arraste para este espaço os ficheiros a carregar até 10MB, tendo em atenção o seu formato e qualidade (PDF, JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens.) (*) Campos de preenchimento obrigatório, sob pena de não ser possível finalizar a submissão do pedido. Declaro que li e aceito os termos e condições apresentados * Declaro que li e aceito a política de tratamento de dados pessoais AdvanceCare * × FORMULÁRIO ENVIADO COM SUCESSO! Para outros assuntos não relacionados com o tema selecionado, utilize a nossa plataforma myAdvanceCare ou contacte-nos pelos canais alternativos disponíveis no verso do seu cartão. Pedidos de reembolso por esta via não são aceites. Com o objetivo de melhorar a qualidade dos serviços prestados e com o intuito de promover a melhoria contínua dos nossos serviços, a AdvanceCare, entidade certificada pelos referenciais da Qualidade NP EN ISO 9001 e NP ISO 10002, disponibiliza através do seu portal um formulário de submissão de pedidos no âmbito de Processos de Autorizações Clínicas. Na utilização deste formulário o utilizador deve tomar conhecimento das seguintes disposições uma vez que é solicitado que forneça previamente dados pessoais. A AdvanceCare S.A é uma entidade subcontratada pela seguradora/entidade para a gestão do seguro/plano. Os dados são recolhidos para a gestão do pedido de autorização clinica e atualização dos seus dados. O fundamento jurídico para o tratamento pela AdvanceCare é a execução enquanto subcontratante das diligências para resposta ao contrato com a seguradora/entidade na gestão de seguros/planos de saúde. Para mais detalhe consulte aqui. O titular dos dados deverá exercer os seus direitos junto da sua seguradora/entidade.Assunto * Nova submissão de pedido de pre-autorização clínica Nova submissão de pedido de pre-autorização clínica Pedido de reavaliação do processo clínico Estado do processo Nova submissão de pedido de pre-autorização clínica Pedido de reavaliação do processo clínico Estado do processo Tipo de utilizador * Segurado / Utente / Beneficiário / Representante Segurado / Utente / Beneficiário / Representante Prestador Convencionado Prestador não convencionado Segurado / Utente / Beneficiário / Representante Prestador Convencionado Prestador não convencionado Seguradora ou subsistema * Açoreana Asisa BIC seguros BNP Paribas Cardif Cimentaçor Cimpor Industria Cruz Vermelha Portuguesa Ensa Seguros Europ Assistance Generali Mudum Seguros Intercement LOGO Lusitania MGEN - Mutuelle Générale de L Education National N Seguros Nossa - PT Popular Seguros Real Vida Seguros SAMS SBC SAMS Mais Sindicato Santander Totta Seguros Tranquilidade UNA Seguros União das Misericórdias Portuguesas Açoreana Asisa BIC seguros BNP Paribas Cardif Cimentaçor Cimpor Industria Cruz Vermelha Portuguesa Ensa Seguros Europ Assistance Generali Mudum Seguros Intercement LOGO Lusitania MGEN - Mutuelle Générale de L Education National N Seguros Nossa - PT Popular Seguros Real Vida Seguros SAMS SBC SAMS Mais Sindicato Santander Totta Seguros Tranquilidade UNA Seguros União das Misericórdias Portuguesas DADOS DO PRESTADOR Tem acesso à funcionalidade de pic web? Sim Não Sim, contudo encontra-se indisponível Sim Não Sim, contudo encontra-se indisponível Por favor vá directamente ao Pic Web. Designação social * Identificação (CIF/Cédula) * Morada * DADOS DO SEGURADO Nº cartão do seguro de saúde / plano de benefícios * Nome * Telemóvel EMAIL DE CONTACTO Email Prestador O email indicado neste campo receberá a notificação de receção deste pedido de contacto Email Cliente DADOS DO PROCESSO Data de ocorrência (data em que ocorre o procedimento) DOCUMENTOS A ANEXAR Faça o download formulário pretendido através dos links que surgem abaixo. Preencha o mesmo e anexe ao pedido, escolhendo a tipificação do documento respetivo. No envio do seu pedido, os ficheiros a anexo, só podem ter, no total de todos os documentos anexos, 10MB. Caso faça o envio através de um dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens, para que os ficheiros anexados tenham o tamanho mais reduzido possível. Pedido de informação clínica cirúrgico internamento Pedido informação clínica dermatologia Pedido informação clínica fisioterapia Pedido informação clínica Meios Complementares de Diagnóstico Pedido informação clínica parto Pedido informação clínica quimioterapia Pedido de informação clínica cirúrgico internamento Pedido de informação clínica dermatologia Pedido informação clínica fisioterapia Pedido informação clínica Meio Auxiliar de Diagnóstico Pedido informação clínica Parto Pedido informação clínica quimioterapia Pedido de Informação Clínica Cirurgico/Internamento Pedido de Informação Clínica Meio Auxiliar de Diagnóstico Pedido de Informação Clínica Parto Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Quimioterapia Pedido de Informação Clínica Cirurgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido de Informação Clínica Dermatologia Pedido de Informação Clínica Fisioterapia Pedido de Informação Clínica Parto Pedido de Informação Clínica Cirúrgico Internamento Pedido Informação Clínica Dermatologia Pedido Informação Fisioterapia Pedido Informação Clínica MCD Pedido Informação Clínica Parto Pedido Informação Clínica Quimioterapia Pedido de Informação Clínico Cirúrgico Internamento Pedido Informação Clínica Dermatologia Pedido Informação Clínica Fisioterapia Pedido Informação Clínica MCD Pedido Informação Clínica Parto Pedido Informação Clínica Parto DESCRIÇÃO DETALHADA DA SITUAÇÃO QUE ORIGINOU A LESÃO/ACIDENTE Arraste para este espaço os ficheiros ou Selecionar Ficheiro Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens. PEDIDO DE INFORMAÇÃO CLÍNICA Arraste para este espaço os ficheiros ou Selecionar Ficheiro Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens. RELATÓRIOS MÉDICOS Arraste para este espaço os ficheiros ou Selecionar Ficheiro Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens. EXAMES COMPLEMENTARES DE DIAGNÓSTICO Arraste para este espaço os ficheiros ou Selecionar Ficheiro Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens. PRÉ-FATURA Arraste para este espaço os ficheiros ou Selecionar Ficheiro Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens. NOTA DE ALTA Arraste para este espaço os ficheiros ou Selecionar Ficheiro Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens. OUTROS Arraste para este espaço os ficheiros ou Selecionar Ficheiro Tenha em atenção o formato e qualidade so documento a anexar ( PDF,JPG, TIF, PNG, GIF, BMP, DOC, DOCX, MSG, XLS, XLSX, TXT ). Em caso de dispositivo móvel confira, nas definições, as permissões de acesso à câmara e galeria de imagens. 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